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LECTURES 


ON 


Practical  Medicine  and  Pathology 


BY 


FRANCIS    DELAFIELD,    M.D.,   LL.D. 


1894 


NEW   YORK 

TROW   DIRECTORY,  PRINTING   &  BOOKBINDING   COMPANY 

201-213  East  Twelfth  Street 


INFLAMMATION. 


The  phenomena  which  are  embraced  under  the  name  of  in- 
flammation are  : 

Changes  in  the  circulation  of  the  blood. 

Escape  of  the  elements  of  the  blood  from  the  vessels. 

Degeneration  or  death  of  tissue. 

Growth  of  new  tissue. 

The  growth  of  pathogenic  micro-organisms  and  the  formation 
by  them  of  toxic  substances. 

These  different  morbid  changes  occur  either  separately  or 
combined  in  a  variety  of  ways. 

We  have,  therefore,  to  consider,  first,  separately  degeneration, 
necrosis,  transudation,  congestion,  emigration,  production,  and 
the  growth  of  micro-organisms  ;  and,  secondly,  the  different  com- 
binations of  these  morbid  processes. 

Degeneration. 

Definition. — We  mean  by  this  term  changes  in  the  substances 
which  compose  the  cells  of  the  viscera,  the  nerve-fibres,  and  the 
muscular  fibres.  We  do  not  include  the  so-called  waxy,  hyaline, 
fatty,  glycogenic,  mucous,  colloid,  and  calcareous  degenerations. 

Etiology. — It  is  characteristic  of  such  a  degeneration  as  this 
that  it  does  not  occur  by  itself,  but  is  always  caused  by  the  pres- 
ence of  some  toxic  substance.  The  poison  may  be  an  inorganic 
one,  such  as  arsenic,  phosphorus,  or  mercury  ;  or  an  organic  one, 
such  as  is  produced  by  the  growth  of  pathogenic  micro-organ- 
isms. How  the  poisons  are  carried  to  the  different  parts  of  the 
body,  and  in  what  way  the  changes  in  the  cells  are  effected,  we 
do  not  know. 

The  poisons  of  the  different  infectious  diseases  vary  as  to  the 
part  of  the  body  which  they  habitually  select.  In  typhoid  and 
typhus  fevers  the   muscles  are  degenerated  ;  in  diphtheria  the 


^  INFLAMMATION. 

Active  congestion  is  often  followed  by  exudative  inflamma- 
tion. Chronic  congestion  is  often  followed  by  productive  in- 
flammation. 

Emigration. 

The  escape  of  the  white  blood-cells  from  the  capillaries  and 
veins  is  usually  associated  with  the  transudation  of  blood-serum, 
but  may  occur  without  it. 

One  cause  for  emigration  is  the  presence  in  the  tissues  near 
the  blood-vessels  of  substances  produced  by  bacteria  which  are 
positively  chemotactic,  that  is,  of  substances  which  attract  white 
blood-cells  toward  them. 

It  is  also  found  that  a  variety  of  irritating  substances  in  the 
tissues  are  capable  of  causing  an  emigration  of  white  cells.  Ap- 
parently whenever  the  emigration  of  white  blood-cells  is  very 
large  it  is  due  to  the  presence  of  pathogenic  bacteria,  especially 
the  streptococci  and  staphylococci. 

The  white  blood  cells  which  have  emigrated  into  the  tissues 
may  remain  for  a  time  as  pus-cells  and  afterward  degenerate  and 
be  absorbed.  Or  they  may  change  into  connective-tissue  cells 
and  form  permanent  new  tissue.  Furthermore  these  cells  are 
capable  of  taking  into  themselves  bacteria  and  other  foreign 
bodies,  and  it  is  probable  that  in  this  way  they  may  be  of  use  in 
limiting  infection. 

It  is  also  to  be  noticed  that  when  a  local  emigration  of  white 
blood-cells  is  caused  by  bacteria  there  is  at  the  same  time  an  in- 
crease in  the  number  of  white  cells  in  the  blood  throughout  the 
body — leucocytosis. 

Production. 

With  or  without  other  inflammatory  changes  there  may  be  a 
growth  of  new  tissue.  This  tissue  follows  the  general  type  of 
connective-tissue  cells  and  basement  substance.  It  is  known  by 
the  names  of  granulation  tissue,  round-celled  tissue,  connective 
tissue,  fibrous  tissue,  tubercle  tissue,  etc.  As  a  rule  the  more 
acute  the  process  the  greater  the  number  of  cells;  the  more 
clironic  the  process  the  greater  the  quantity  of  basement  sub- 
stance. 

In  an  acute  inflammation  the  production  of  new  tissue  may 
occur  by  itself,  but  is  more  frequently  associated  with  exudation 
and   emisfiation.     In  chronic  inflammations  the  growth  of  new 


INFLAMMATION.  7 

tissues  is  often  not  attended  with  congestion,  emigration,  or  exu- 
dation. 

Whenever  in  any  inflammation  there  is  at  the  first  a  produc- 
tion of  new  tissue  that  inflammation  regularly  goes  on  to  assume 
the  sub-acute  or  chronic  form. 

Micro-organisms. 

Concerning  the  whole  subject  of  micro-organisms  the  student 
should  read  the  article  on  "  The  Biology  of  Bacteria,  Infection, 
and  Immunity,"  by  Dr.  Welch  in  tlie  "  American  Text-book  of 
the  Theory  and  Practice  of  Medicine." 

As  regards  the  relationship  of  micro-organisms  with  inflam- 
mation, it  has  been  demonstrated  that  the  organisms  tliemselves 
and  the  products  of  their  growth  are  capable  of  causing  exuda- 
tion, emigration,  degeneration,  necrosis,  and  the  growth  of  new 
tissue.  They  seem  to  be  of  most  importance  in  connection  witli 
the  purulent  and  necrotic  inflammations. 

The  particular  form  of  inflammation  excited  by  the  organisms 
seems  to  depend  upon  the  number  of  organisms  present  and  the 
virulence  of  the  toxines  which  they  produce. 

In  the  severer  local  inflammations,  which  are  accompanied  by 
fever  and  other  constitutional  symptoms,  these  symptoms  are 
principally  due  to  the  toxines  produced  by  the  growth  of  the 
organisms. 

In  classifying  and  naming  the  different  forms  of  inflammation 
it  is  convenient  to  name  them  according  to  the  most  prominent 
of  the  different  changes  which  go  to  make  up  the  whole  process. 

We  distinguish  : 

I.  Exudative  inflammation. 

(a)  Simple  exudative  inflammation. 
(/^)  Purulent  exudative  inflammation. 
I      2.  Productive  inflammation. 

(a)  Simple  acute  productive  inflammation. 
{3)  Productive  inflammation  with  exudation. 
(c)  Chronic  productive  inflammation. 

3.  Necrotic  inflammation. 

I.  Exudative  Inflammation. — An  exudative  inflammation  is  one 
characterized  by  the  presence  of  an  exudate — serum,  fibrin,  and 
pus.  The  production  of  such  an  exudation  may  or  may  not  be 
attended  with  changes  in  the  inflamed  tissues.     The  process  may 


6  INFLAMMATION. 

run  an  acute,  a  subacute,  or  a  chronic  course.  The  character  of 
the  inflamed  tissue,  whether  connective  tissue,  a  mucous  mem- 
brane, or  a  viscus,  modifies  the  character  of  the  inflammation. 

We  distinguish,  therefore  : 

(a)  Simple  exudative  inflammation. 

{b)  Exudative  inflammation  with  large  quantities  of  pus. 

{a)  So  far  as  the  exudate  is  concerned,  we  know  by  direct 
observation  what  it  is  and  how  it  finds  its  way  into  tlae  tis- 
sues. 

In  the  inflamed  tissue  there  is  first  a  dilatation  of  the  arteries, 
veins,  and  capillaries,  and  an  increased  rapidity  of  the  circulation 
of  the  blood.  Then  the  blood-current  becomes  slower  ;  while 
white  blood-cells  accumulate  in  the  veins  and  capillaries,  and  ad- 
here to  their  walls.  This  is  the  condition  of  "acute  congestion," 
and  the  morbid  process  may  not  advance  beyond  this  If  it  does 
advance  farther,  the  white  blood-cells  change  their  shape,  find 
their  way  between  the  endothelial  cells  of  the  blood-vessels, 
through  their  walls,  and  appear  on  the  outside  of  the  vessels  in 
the  tissue.  This  is  called  "emigration"  Red  blood-cells  in 
smaller  numbers  may  also  pass  through  the  walls  of  the  capillaries 
and  veins,  and  this  is  called  "  diapedesis."  At  the  same  time  the 
plasma  of  the  blood  transudes  through  the  walls  of  the  vessels 
and  infiltrates  the  tissues  as  serum  ;  while  by  the  union  of  sub- 
stances contained  in  the  blood-plasma  and  in  the  white  blood- 
cells,  fibrin  is  formed. 

In  this  manner  are  elaborated  the  inflammatory  products — pus, 
serum,  and  fibrin.  The  pus-cells  are  emigrated  white  blood- 
cells  ;  the  serum  is  part  of  the  plasma  of  the  blood  ;  the  fibrin  is 
produced  by  a  union  of  the  fibrinogen  in  solution  in  the  blood- 
plasma  with  substances  contained  in  the  white  blood-cells,  and 
appears  coagulated  in  the  form  of  granules,  amorphous  masses, 
or  a  reticulum. 

The  relative  quantity  of  pus,  serum,  or  fibrin  varies  in  differ- 
ent cases. 

In  "simple  exudative  inflammation  "  we  find  no  other  morbid 
changes  than  the  congestion  and  the  exudation  ;  the  tissues  re 
main   unaltered      When  the  inflammation   has  subsided  all  the 
parts  return  to  their  natural  condition. 

It  is  in  connective  tissue  that  a  simple  exudative  inflammation 
is  seen  in  its  most  typical  form.  The  structure  of  connective 
tissue  is  simple — a  basement  substance,  cells,  blood-vessels,  lym- 


INFLAMMATION.  9 

pliatics,  and  nerves.  The  inflammation  is  attended  with  an  in- 
creased quantity  of  blood  in  the  vessels,  more  or  less  swelling  of 
the  basement  substance  and  cells,  and  the  exudation  collected  in 
the  natural  cavities  of  the  tissue. 

The  structure  of  the  mucous  membranes  is  more  complex. 
They  are  all  composed  of  a  layer  of  epithelium,  of  a  connective- 
tissue  stroma  containing  the  blood-vessels,  nerves,  and  lymphatics, 
and  of  glands  which  produce  mucus.  The  inflammation  not  only 
causes  the  same  congestion  and  exudation  in  the  stroma,  but 
there  are  also  changes  in  the  epithelium  and  the  glands.  In  the 
epithelium  there  is  a  more  active  desquamation  of  old  cells  and 
growth  of  new  cells  ;  sometimes  superficial  ulcers  are  formed. 
The  function  of  the  mucous  glands  is  interfered  with  At  first 
the  production  of  mucus  is  stopped,  later  it  is  increased  and 
altered.  The  increased  production  of  mucus  is  regularly  attended 
with  a  diminution  of  the  congestion  and  swelling  of  the  mucous 
membrane.  Such  an  inflammation  in  a  mucous  membrane  is 
often  called  "acute  catarrhal  inflammation  " 

The  viscera  are  composed  of  a  connective-tissue  stroma  con- 
taining the  blood-vessels,  lymphatics,  and  nerves,  and  of  cells. 
The  cells  are  peculiar  to  each  viscus,  and  are  concerned  in  per- 
forming the  functions  of  the  A'iscus. 

The  principal  changes  effected  by  the  inflammation  are  the 
congestion  and  consequent  swelling  and  the  inability  of  the  vis- 
ceral cells  to  perform  their  proper  functions.  The  quantity  of 
exudation  is  small. 

{i>)  In  exudative  inflammation  with  an  excessive  quantity  of 
pus,  or  purulent  inflammation,  the  excessive  number  of  pus-cells 
may,  or  may  not,  be  accompanied  by  serum  and  fibrin.  Such  an 
excessive  number  of  pus-cells  is  due  to  an  increased  emigration 
of  white  blood-cells. 

The  inflammation  is  of  a  more  severe  type  than  a  simple  ex- 
udative inflammation.  The  pus-cells  infiltrate  connective  tissue, 
they  are  mixed  with  the  serum  in  the  serous  cavities  and  with  the 
mucus  on  the  surfaces  of  the  mucous  membranes,  but  they  do  not 
form  abscesses. 

II.  Productive  Inflammation  : 

[a)  Simple  acute  productive  inflammation. — In  this  form 
there  is  no  exudation,  no  serum,  fibrin,  or  pus.  Congestion  is 
sometimes  visible  after  death,  but  by  no  means  always.  The 
inflammatory  product  consists  of  new  cells  formed  from  the  old 


lO  INFLAMMATION. 

conpective-tissue  cells.  The  pia  mater  and  the  peritoneum  ofter 
the  best  examples  of  this  form  of  inflammation. 

{b)  Productive  inflammation  with  exudation. — In  this  form 
of  inflammation  the  changes  in  the  blood-vessels,  the  exudation 
and  emigration,  the  formation  of  serum,  fibrin,  and  pus  are  well 
marked,  but  in  addition  there  is  from  the  first  a  growth  of  new 
tissue.  This  new  tissue  at  first  consists  principally  of  cells,  later 
a  basement  substance  and  blood-vessels  are  added.  This  form  of 
inflammation  has  a  marked  disposition  to  continue  for  a  long 
time  in  a  sub-acute  or  chronic  form. 

In  connective  tissue  the  serum,  fibrin,  and  pus  are  found  in 
varying  quantities.  The  new  tissue  forms  thickenings,  and  ad- 
hesions. 

In  the  mucous  membranes  the  inflammation  involves  the 
stroma,  and  it  is  in  the  stroma  that  the  exudation  is  infiltrated 
and  the  new  tissue  formed.  The  glandular  coat  may  remain  un- 
changed, or  be  the  seat  of  catarrhal  inflammation. 

In  the  viscera  the  quantity  of  the  inflammatory  product 
varies.  The  new  tissue  is  formed  in  the  stroma.  The  visceral 
cells  undergo  more  or  less  atrophy  or  degeneration. 

{c)  In  chronic  productive  inflammation  the  inflammatory 
product  is  round  celled  tissue,  granulation-tissue,  or  connective 
tissue.  In  some  cases  this  is  the  only  change,  in  others  there  is 
added  an  exudation  from  the  blood-vessels,  or  degeneration  of 
cells.  The  new  tissue  that  is  formed  may  degenerate  or  become 
calcified. 

In  connective  tissue  this  form  of  inflammation  produces  thicken- 
ings and  adhesions,  and  serum  in  the  serous  cavities. 

In  mucous  membranes  the  growth  of  new  tissue  is  in  the  stroma. 
This  is  thickened,  either  diffusely,  or  in  the  form  of  polypoid 
growths.  The  layer  of  epithelium  may  be  thickened  or  thinned. 
The  mucous  glands  are  atrophied,  or  hypertrophied,  or  become 
cystic.  The  production  of  mucus  is  diminished,  or  increased,  or 
altered.  This  condition  in  the  mucous  membranes  is  commonly 
called  a  "chronic  catarrhal"  inflammation. 

In  the  viscera  there  is  a  growth  of  indifferent  tissue,  or  of  con- 
nective tissue,  in  the  stroma.  The  visceral  cells  are  compressed, 
or  degenerated,  or  fatty,  or  disappear.  The  functions  of  the  vis- 
cus  are  seriously  interfered  with.  In  the  viscera  this  is  often 
called  an  "  interstitial  "  inflammation. 

The  most  marked  features  of  this  form  of  inflammation  are  its 


INFLAMMATION.  1 1 

slow  course  and  its  tendency  to  continue.  The  lesions  of  chronic 
productive  inflammation,  especially  in  old  persons,  are  by  some 
believed  to  be  due  to  chronic  degeneration. 

III.  Necrotic  Inflammation. — In  this  form  of  inflammation,  in 
addition  to  the  congestion  and  exudation,  there  is  added  death 
or  degeneration  of  parts  of  the  tissues  in  which  the  inflammation 
exists.  This  character  of  the  inflammation  is  given  to  it  by  the 
presence  and  growth  of  pathogenic  bacteria.  The  bacteria  regu- 
larly present  are  the  staphylococcus  pyogenes  aureus  and  albus, 
and  the  streptococcus  pyogenes.  They  frequently  occur  together 
in  the  same  inflammatory  process. 

Such  an  inflammation,  when  it  occurs  in  connective  tissue, 
produces  abscesses.  A  circumscribed  portion  of  tissue  is  con- 
gested, infiltrated  with  serum,  fibrin,  and  pus,  and  parts  of  the 
tissue  die.  Tlie  dead  tissue  softens,  breaks  down,  and  cavities 
are  formed  which  contain  serum,  pus-cells,  and  portions  of  dead 
tissue. 

In  mucous  membranes  there  are  congestion,  exudation  of 
serum  rich  in  fibrino-plastic  substances,  emigration  of  white 
blood-cells,  and  necrosis  of  tissue. 

The  fibrin  infiltrates  the  stroma,  and  coagulates  on  the  sur- 
faces of  tlie  mucous  membranes  so  as  to  form  false  membranes. 
The  pus-cells  are  entangled  in  the  fibrin.  The  necrosis  involves 
only  the  epithelium,  which  passes  into  the  condition  of  coagula- 
tion necrosis,  and  forms  part  of  the  false  membranes  ;  or  it  in- 
volves also  the  stroma.  The  death  of  the  epithelium  forms 
superficial  erosions,  that  of  the  stroma  ulcers  of  varying  size  and 
depth. 

Such  an  inflammation  of  the  mucous  membranes  is  called 
"  croupous."  or  "diphtheritic."  We  also  find  with  catarrhal  and 
productive  inflammations  circumscribed  necrosis  of  the  epi- 
thelium. 

In  the  viscera  we  find  congestion,  exudation  of  albuminous 
serum,  and  emigration  of  white  blood-cells.  In  addition  there 
may  be  degeneration  or  death  of  the  visceral  cells  ;  or  death  of 
portions  of  the  stroma  with  groups  of  cells,  and  the  formation  of 
abscesses. 

This  variety  of  inflammation  is  of  severe  type,  is  accompanied 
with  marked  symptoms,  and  after  it  has  subsided,  leaves  changes 
in  the  tissues. 

In  connective   tissue  the  cavities  of  the  abscesses  are  filled 


12  INFLAMMATION. 

first  with  granulation  tissue,  and  afterward  with  cicatricial  tis- 
sue. 

In  the  mucous  membranes  the  dead  epithelial-cells  may  be 
replaced  by  new  cells  of  the  same  kind,  but  the  ulcers  formed 
by  the  death  of  the  stroma  have  to  be  filled  first  with  granulation 
tissue,  and  later  by  cicatricial  tissue. 

In  the  viscera  the  degenerated  cells  may  be  replaced  by  new 
visceral  cells,  but  the  abscess  cavities  are  filled  first  with  granu- 
lation tissue,  and  later  with  cicatricial  tissue. 

The  treatment  of  the  different  forms  of  inflammation  is  a 
matter  of  practical  importance. 

In  exudative  inflammation  the  most  efficient  treatment  is  the 
use  of  local  means  which  cause  contraction  of  the  blood-vessels. 
Such  a  contraction  can  be  caused  by  the  application  of  cold,  of 
heat,  and  of  astringents.  Somewhat  less  certain  as  a  local  treat- 
ment, although  apparently  often  of  service,  is  the  use  of  counter- 
irritation,  or  of  local  blood  letting,  by  which  the  congestion  of 
the  inflamed  tissues  seems  to  be  relieved.  Whether  a  local  in- 
flammation is  favorably  affected  by  general  blood-letting  is  un- 
certain. 

In  some  cases,  by  no  means  in  all,  this  form  of  exudative 
inflammation  seems  to  be  favorably  affected  by  the  use  of  drugs. 
If  we  dilate  the  small  arteries  throughout  the  body,  it  seems 
probable  that  we  can  diminish  the  congestion  of  any  one  circum- 
scribed part  of  the  body,  and  so  we  give  aconite,  veratrum  viride, 
and  nitro-glycerine. 

In  the  mucous  glands  we  see  that,  as  a  larger  quantity  of 
mucus  is  produced  the  congestion  subsides,  and  so  we  give  drugs 
which  are  likely  to  increase  the  production  of  mucus,  such  as 
ipecac,  antimony,  and  pilocarpine. 

Then  there  are  certain  drugs  which  we  use  empirically  :  calo- 
mel or  sulphate  of  magnesia  in  small  doses  frequently  repeated 
for  a  few  hours;  opium  given  for  a  longer  time  :  in  the  case  of 
some  of  the  mucous  membranes,  large  doses  of  ipecac. 

In  the  forms  of  exudative  inflammation  with  death  of  tissue, 
suppuration,  and  the  growth  of  pathogenic  bacteria,  it  has  been 
conclusively  shown  that,  if  the  bacteria  can  be  excluded  the 
inflammation  will  not  assume  this  character.  When,  however, 
such  an  inflammation  is  once  established,  it  is  not  easy  to  destroy 
the  bacteria  and  subdue  the  inflammation  by  the  local  use  of 
germicides.     On  the  other  hand,  the  evacuation  of  collections  of 


THE   PIA   MATER.  13 

pus  and  of  serum  with  antiseptic  precautions  and  complete  clos- 
ure of  the  wound,  is  regularly  followed  by  subsidence  of  the  in- 
flammation. 

When  a  production  of  new  tissue  is  added  to  an  exudative 
inflammation,  we  employ  the  same  means  of  treatment  as  for  an 
exudative  inflammation,  but  without  the  same  probability  of  suc- 
cess. Such  inflammations  are  much  more  likely  to  become 
chronic,  or  to  cause  permanent  changes. 

The  chronic  productive  inflammations  are  much  less  amen- 
able to  treatment.  The  internal  administration  of  drugs,  except 
in  the  case  of  syphilis,  is  of  little  avail.  We  rely  principally  on 
local  treatment,  regulation  of  the  diet  and  mode  of  life,  and  cli- 
mate ;  but  it  has  long  been  believed  that  preparations  of  mer- 
cury, and  the  iodide  of  potash,  are  of  use  in  some  examples  of 
this  form  of  inflammation. 

The  Pia  Mater. 

The  external  surface  of  the  brain  is  overlaid  by  a  connective- 
tissue  membrane  which  covers  the  convolutions,  dips  down  into 
the  sulci,  and  extends  into  the  ventricles.  This  membrane  is 
abundantly  supplied  with  blood-vessels,  and  from  it  numerous 
vessels  extend  into  the  brain,  so  that  any  disturbance  in  the  cir- 
culation of  the  blood  in  the  pia  mater  involves  a  disturbance  in 
the  circulation  of  the  blood  in  the  brain  also. 

The  connective  tissue  which  makes  up  the  pia  mater  is  ar- 
ranged in  a  series  of  membranes  and  fibres  reinforced  by  elastic 
tissue,  so  arranged  as  to  form  a  spongy  membrane  containing 
numerous  cavities  more  or  less  filled  with  fluid.  These  cavities 
are  continuous  with  the  perivascular  spaces  which  surround  the 
vessels  that  pass  from  the  pia  mater  into  the  brain.  The  outer 
layers  of  the  pia  mater  are  the  most  compact,  and  are  covered  on 
their  outer  surface  by  a  continuous  layer  of  endothelial  cells. 
This  external  layer  of  the  pia  mater  is  often  described  as  a  sepa- 
rate membrane  called  the  "  arachnoid,"  but  it  is  really  only  part 
of  the  pia. 

The  deeper  layers  of  the  pia  contain  the  blood-vessels.  The 
membranes  and  fibres  which  compose  the  pia  mater  are  partly 
coated  with  cells,  which  have  irregular  and  delicate  cell-bodies 
and  large,  distinct  nuclei. 

In  all  inflammations  of  the  pia  mater  the  inflammatory  prod- 


14  THE   PIA   MATER. 

ucts  regularly  collect  in  the  spaces  within  it.  Only  occasion- 
ally do  we  find  them  on  its  free  surface. 

The  pia  mater  is  frequently  thickened,  opaque,  and  white, 
either  in  diffuse  patches,  or  along  the  course  of  the  vessels.  In 
other  cases,  single  or  multiple  white  spots  of  the  size  of  a  pin's 
head,  or  smaller,  may  be  seen  in  the  membrane,  not  appreciably 
elevated  above  the  surface,  but  due  to  localized  thickening. 
These  slight  opacities  of  the  pia  mater  are  commonly  believed 
to  be  dependent  upon  repeated  congestions  of  the  membrane, 
or  upon  chronic  meningitis,  but  there  is  no  evidence  that  this  is 
always  the  case.  They  are  most  frequently  found  in  old  persons, 
but  may  exist  at  any  age,  and  do  not  necessarily  indicate  the  pre- 
existence  of  disease,  although  similar  appearances  are  common 
in  the  chronic  insane  and  in  drunkards. 

Congestion  and  Anemia. — There  can  be  little  question  that 
the  quantity  of  blood  contained  in  the  vessels  of  the  pia  mater 
varies  at  different  times,  and  that  any  considerable  increase  or 
diminution  of  the  quantity  of  blood  is  likely  to  give  cerebral 
symptoms.  In  the  human  subject,  however,  our  knowledge  of 
this  subject  is  as  yet  indefinite. 

CEdema. — The  quantity  of  serum  beneath  the  pia  mater  and 
in  its  cavities  is  very  variable.  It  may  accumulate  as  a  result  of 
atrophy  of  the  brain-substance  or  of  venous  hyperaemia,  and  may 
be  accompanied  by  oedema  of  the  brain-substance  also.  It  is 
not  infrequent  to  find  in  hospital  patients  suffering  from  chronic 
nephritis,  cardiac  or  pulmonary  disease,  or  chronic  alcoholism, 
a  very  considerable  quantity  of  serum  in  this  situation,  and  yet 
the  patient  has  been  free  from  cerebral  symptoms.  In  other 
cases,  again,  this  same  effusion  affords  the  only  explanation  of 
grave  cerebral  symptoms. 

ACUTE    MENINGITIS. 

Lesions. — The  ordinary  form  of  acute  inflammation  of  the  pia 
mater  is  the  exudative,  but  occasionally  the  inflammation  is  of 
pure  productive  type  without  exudation.  Either  form  of  inflam- 
mation, however,  is  attended  with  the  same  symptoms. 

In  acute  productive,  or  cellular,  meningitis  the  pia  mater  is 
congested,  its  surface  is  dry  and  lustreless,  it  is  somewhat  opaque, 
it  is  not  at  all  infiltrated  with  serum.  These  changes  in  the  gross 
appearance  of  the  membrane  are  not  marked  and  are  easily  over- 
looked, but  the  minute  changes  are  more  decided.     There  is  an 


THE   PIA   MATER.  1 5 

abundant  production  of  cells  somewhat  resembling  the  cells 
which  coat  the  surfaces  of  the  membranes  and  fibres  which  make 
up  the  pia  mater.  This  cell-growth  is  general,  involving  the  pia 
mater  over  most  of  the  surface  of  the  brain,  but  the  cells  are 
much  more  numerous  in  some  places  than  in  others.  The  in- 
flammation, then,  is  one  which  results  in  the  production,  not  of 
fibrin,  serum,  or  pus,  but  of  new  connective-tissue  cells. 

In  acute  exudative  meningitis  there  is  an  accumulation  of 
serum,  fibrin,  and  pus  in  the  meshes  of  the  pia  mater  and  along 
the  course  of  the  vessels,  rarely  on  the  surface  of  the  pia.  Some- 
times one,  sometimes  another  of  these  exudations  preponderates, 
giving  rise  to  serous,  fibrinous,  or  purulent  forms  of  the  inflam- 
mation. The  absolute  quantity  of  the  exudation  varies  greatly. 
The  quantity  of  exudation  may  be  so  small  that  the  pia  looks 
nearly  normal  to  the  naked  eye,  and  the  pus  and  fibrin  can  only 
be  seen  with  the  microscope.  More  frequently  the  quantity  of 
exudation  is  considerable,  and  often  very  large,  even  sufficient  to 
flatten  the  convolutions  of  the  brain.  The  cortical  portion  of 
the  brain  may  be  oedematous,  or  degenerated,  or  infiltrated  with 
minute  hemorrhages.  Very  often  the  inflammation  extends  to 
the  ventricles,  which  then  contain  purulent  serum.  In  children 
the  ventricular  lesion  is  regularly  well  marked,  the  ventricles  are 
dilated,  and  contain  large  quantities  of  purulent  serum.  In 
adults  such  a  distention  of  the  ventricles  occurs  less  frequently. 
The  inflammation  of  the  ventricles  may  persist  for  days  and 
weeks  after  the  subsidence  of  the  meningitis. 

The  exudation  may  cover  the  whole  surface  of  the  brain,  or 
be  confined  to  the  base,  or  to  the  convexity.  It  often  extends 
down  in  the  pia  mater  of  the  cord,  and  the  roots  of  the  cranial 
nerves  may  also  be  involved. 

In  the  purulent  forms  of  acute  meningitis,  bacteria  have  been 
found.  The  ordinary  streptococcus  of  purulent  inflammation, 
the  diplococcus  pneumoniae,  the  diplococcus  intra-cellularis,  a 
bacillus  like  that  of  typhoid  fever,  have  been  described.  In  an 
epidemic  of  cerebro-spinal  meningitis  Bonome  has  found  a  spe- 
cial form  of  streptococcus. 

Causes. — Acute  meningitis  occurs  under  four  entirely  different 
conditions.  It  is  produced  by  injuries,  by  the  extension  of  in- 
flammations from  the  cranial  bones,  the  ear,  the  dura  mater,  and 
by  infection  from  streptococcus  inflammation  in  other  parts  of 
the  body. 


l6  THE   PIA   MATER. 

It  complicates  pneumonia,  rheumatism,  nephritis,  and  many 
of  the  infectious  diseases. 

It  occurs  as  a  primary  lesion  without  discoverable  cause. 

It  is  the  characteristic  lesion  of  the  infectious  disease  called 
epidemic  cerebro-spinal  meningitis. 

Syt7ipto7ns. — The  idiopathic  cases.  It  is  difficult  to  distinguish 
these  cases  from  sporadic  cases  of  cerebro-spinal  meningitis,  and 
our  descriptions  of  idiopathic  meningitis  are  probably  very  much 
modified  by  our  observations  of  the  epidemic  disease.  The  idio- 
pathic form  seems  to  be  more  common  in  children. 

The  invasion  of  the  disease  may  be  preceded  by  a  prodromic 
period  characterized  by  conjunctivitis,  nausea  and  vomiting, 
headache,  irritability  of  temper,  sleeplessness,  and  general  ma- 
laise ;  or  it  may  be  sudden,  with  fever,  headache,  convulsions, 
delirium,  and  vomiting.  The  cases  vary  as  to  which  one  of  these 
symptoms  is  the  prominent  one  at  the  outset.  Either  the  head- 
ache, the  convulsions,  the  delirium,  or  the  vomiting  may  be  es- 
pecially marked. 

When  the  disease  is  fairly  developed  the  headache  is  contin- 
ued and  severe.  Throughout  the  disease  perhaps  the  most 
prominent  symptoms  are  restlessness  and  stupor.  The  restless- 
ness ranges  from  irritability  and  sleeplessness  up  to  violent  de- 
lirium ;  the  stupor  from  apathy  up  to  coma.  In  many  patients 
the  restless  condition  occupies  the  earlier  days  of  the  disease, 
and  the  stupor  is  gradually  developed  later.  In  others  the  rest- 
lessness and  stupor  alternate  ;  or  either  one  may  predominate 
throughout  the  disease. 

Involuntary  contractions  of  groups  of  muscles,  especially  of 
those  of  the  face,  are  often  present.  Unilateral  or  general  con- 
vulsions occur  in  some  of  the  cases. 

Localized  or  general  hyperaesthesia  of  the  skin  may  exist.  If 
the  inflammation  extends  down  to  the  pia  mater  of  the  cord, 
there  is  tenderness  and  contraction  of  the  muscles  of  the  neck. 

As  the  inflammation  involves  the  roots  of  the  cranial  nerves, 
photophobia,  blindness,  strabismus,  painful  hearing,  and  deaf- 
ness are  developed. 

The  vomiting  which  belongs  to  the  outset  of  the  disease  may 
continue,  or  it  may  not  begin  until  later. 

The  tongue  is  coated,  and  in  bad  cases  becomes  dry. 

Constipation  is  the  rule,  but  diarrhoea  and  involuntary  move- 
ments may  come  on  in  the  last  days  of  fatal  cases. 


THE   PI  A   MATER.  1 7 

The  urine  is  diminished  in  quantity  ;  it  may  contain  a  little 
albumin  and  a  few  casts. 

The  temperature  usually  runs  between  ioo°  F.  and  104°  F.  ; 
it  is  apt  to  follow  an  irregular  course. 

The  pulse  is  at  first  rapid,  then  slow,  and,  in  the  fatal  cases, 
again  rapid  and  weak,  but  it  may  be  rapid  throughout  the  dis- 
ease. 

In  children  the  course  of  the  disease  may  be  the  same  as  in 
adults.  Often,  however,  the  excessive  development  of  the  in- 
flammation of  the  lateral  ventricles  and  their  distention  with  se- 
rum, causes  a  difference  in  the  symptoms.  In  some  children 
almost  the  only  symptoms  are  a  febrile  movement  and  convul- 
sions alternating  with  stupor.  In  others  the  course  of  the  dis- 
ease is  like  that  of  tubercular  meningitis. 

The  duration  of  an  acute  meningitis  is  from  thirty-six  hours 
to  four  weeks.  The  ordinary  duration  is  from  seven  to  fourteen 
days. 

The  prognosis  is  bad,  but  not  hopeless. 

Secondary  Acute  Meningitis. — First  there  are  the  symptoms 
of  the  primary  inflammation,  and  then  those  of  the  meningitis. 

If  the  meningitis  is  secondary  to  an  acute  otitis  there  are  first 
the  fever,  prostration,  and  severe  pain  belonging  to  the  otitis. 
Then  the  patients  become  worse,  the  prostration  is  more  marked, 
the  temperature  is  higher,  alternating  delirium  and  stupor  are 
developed,  there  are  contractions  of  the  muscles  of  the  face,  slow 
pulse,  and  finally  coma.  But  it  must  be  remembered  that  a  se- 
vere acute  otitis,  especially  in  children,  may  give  marked  cere- 
bral symptoms  without  meningitis. 

If  the  meningitis  follows  a  chronic  otitis  there  will  be  the  his- 
tory of  the  ear  trouble  extending  back  for  months  or  years  ;  then 
suddenly  come  on  the  symptoms  of  the  meningitis — fever,  head- 
ache, alternating  delirium  and  stupor,  coma. 

Complicating  Meningitis. — The  diseases  which  are  liable  to 
be  complicated  by  meningitis  are  all  of  them  capable  of  givino- 
marked  cerebral  symptoms  without  any  inflammation  of  the  pia 
mater.  When  a  complicating  meningitis  really  is  developed,  the 
only  difference  is  that  the  symptoms  are  more  marked  and  ap- 
proach more  closely  to  those  of  an  idiopathic  meningitis. 

Treatment. — The  indications  for  treatment  are  to  diminish  the 
severity  of  an  acute  exudative  inflammation,  to  alleviate  the  pain, 
and  to  nourish  the  patient. 


15  THE   PIA    MATER. 

The  measures  directed  toward  the  inflammation  are  most  effi- 
cacious during  the  early  days  of  the  disease.  We  employ  continu- 
ous cold  over  the  head  by  ice-bags  or  the  rubber  coil,  sometimes 
blood-letting  from  the  temples  and  the  back  of  the  neck,  and  the 
internal  administration  of  calomel,  sulphate  of  magnesia,  opium, 
the  iodide  of  potash,  or  ergot. 

The  pain  and  restlessness  may  be  controlled  by  the  bromides, 
chloral,  or  opium. 

The  patients  are  to  be  kept  perfectly  quiet  in  a  darkened 
room,  on  a  fluid  diet,  with  the  addition  of  alcoholic  stimulants 
when  the  heart's  action  begins  to  fail.  The  bowels  are  kept  open 
by  mild  laxatives  or  enemata. 

CHRONIC    MENINGITIS. 

True  chronic  meningitis  is  a  very  real  and  serious  lesion.  It 
is  not  to  be  confounded  with  tlie  simple  opacities  and  thickenings 
of  the  pia  mater  which  are  so  common  in  adult  life. 

Lesions. — Either  the  pia  mater  or  the  base  of  the  brain  alone 
may  be  inflamed  (basilar  meningitis),  or  the  pia  mater  over  the 
convexity  alone  or  the  entire  pia  mater,  or  circumscribed  patches 
of  the  membrane.  The  pia  mater  is  thickened  and  opaque,  the 
thickening  being  sometimes  very  considerable.  There  is  a  for- 
mation of  new  connective  tissue  and  a  production  of  pus,  fibrin, 
and  serum  ;  the  relative  quantity  of  these  inflammatory  products 
varies  in  different  cases.  Firm  and  extensive  adhesions  may  be 
formed  between  the  dura  mater  and  the  pia  mater.  Not  infre- 
quently the  cortical  portions  of  the  brain  participate  in  the  mor- 
bid process,  and  we  find  an  infiltration  of  small  spheroidal  cells 
around  the  blood-vessels,  thickening  of  the  walls  of  the  vessels, 
and  degenerative  changes  and  atrophy  of  the  brain  tissue.  New 
connective  tissue  may  also  form  in  the  brain  substance,  and  the 
latter  may  become  adherent  to  the  pia  mater.  The  ventricles  of 
.the  brain  may  be  much  dilated  and  distended  with  serum,  their 
ependyma  may  be  thickened  and  roughened. 

Causes. — Chronic  meningitis  may  be  caused  by  blows  on  the 
head,  and  by  fractures  and  inflammations  of  the  cranial  bones. 
Sometimes  the  injury  to  the  head  antedates  by  several  years  the 
symptoms  of  the  meningitis.  It  is  often  associated  with  pachy- 
meningitis, with  tumors  of  the  brain,  and  with  chronic  endar- 
teritis of  the  cerebral  arteries.     It  is  the  direct  result  of  syphilis. 


THE   PIA   MATER.  I9 

It  occurs  with  chronic  nephritis,  with  chronic  alcoholism,  and  in 
persons  who  are  badly  nourished  and  of  dissipated  habits.  It  is 
regularly  found  in  the  general  paralysis  of  the  insane. 

Symptoms. — The  course  of  the  disease  is  that  of  an  inflamma- 
tion, chronic  from  the  outset,  and  with  exacerbations  from  time 
to  time.  The  symptoms  are  at  first  obscure  and  intermittent,  and 
vary  much  in  different  individuals  as  to  their  number  and  dis- 
tinctiveness. So  the  diagnosis  is  always  difficult  and  sometimes 
quite  impossible. 

The  patients  complain  of  more  or  less  headache — continuous 
or  intermittent.  The  mental  faculties  and  the  temper  gradually 
deteriorate,  and  such  a  change  may  go  on  to  complete  insanity. 
From  time  to  time  there  are  attacks  of  unconsciousness,  of  stu- 
por, of  delirium,  of  muscular  contractions  or  rigidity,  of  aphasia, 
of  general  convulsions,  or  of  vomiting.  After  a  time  the  nutrition 
is  impaired,  and  there  is  a  gradual  loss  of  flesh  and  strength.  At 
the  times  when  the  symptoms  are  most  marked  there  may  be  a 
moderate  rise  of  temperature. 

Chronic  meningitis  usually  lasts  for  a  number  of  years,  but  it 
may  happen  that  the  early  symptoms  are  slight  and  that  at  some 
time  severe  symptoms  are  suddenly  developed,  as  if  of  an  acute 
cerebral  lesion. 

The  patients  become  insane,  or  die  with  marked  cerebral  symp- 
toms, or  in  a  condition  of  emaciation  and  exhaustion. 

Treatme7it. — The  first  point  to  determine  is  whether  the  patient 
has  had  syphilis.  If  this  is  the  case,  the  use  of  mercury  and  the 
iodide  of  potash  may  be  of  much  service.  In  the  cases  due  to 
other  causes  there  seems  to  be  no  direct  treatment  for  the  menin- 
gitis. The  improvement  of  the  general  health,  and  the  allevia- 
tion of  symptoms  must  be  attempted,  but  as  a  rule  the  patients 
get  worse. 

TUBERCULAR    MENINGITIS. 

Tubercular  inflammation  of  the  pia  mater  behaves  differently 
in  children  and  in  adults,  so  that  it  is  necessary  to  describe  the 
disease  separately  according  to  tlie  age  of  the  patient. 

I.  Tubercular  Meningitis  in  Children.  Lesions. — The  dura 
mater  is  usually  unchanged,  but  there  may  be  miliary  tubercles 
on  its  inner  surface.  The  surface  of  the  brain  is  flattened  by  the 
pressure  of  the  fluid  which  distends  the  ventricles.  The  inflam- 
matory process  is  a  combination  of  tubercular  and  of  exudative 


20  THE   PIA   MATER. 

or  cellular  inflammation,  either  one  of  which  may  predomi- 
nate. The  tubercles  are  very  small  and  transparent,  or  large  and 
white.  They  are  composed  of  simple  aggregations  of  small  cells, 
or  of  well-formed  tubercle  tissue  arranged  around  blood-vessels. 
The  vessels  show  tlie  changes  of  obliterating  endarteritis.  The 
cellular  inflammation  produces  new  connective-tissue  cells,  the 
exudative  inflammation  produces  serum,  fibrin,  and  pus.  The  in- 
flammation is  often  confined  to  the  base  of  the  brain,  but  may 
extend  over  its  entire  surface,  or  be  confined  to  the  convexity. 
The  tubercles  are  most  numerous  in  the  pia  mater  over  and  in 
the  sulci. 

The  ventricles  of  the  brain  are  much  dilated  and  distended 
with  serum.  Their  ependyma  is  thickened  and  studded  with  very 
small  miliary  tubercles.  The  brain  tissue  around  the  ventricles 
is  softened.  There  ma}^  be  similar  lesions  in  the  pia  mater  of  the 
cord. 

Such  a  tubercular  meningitis  is  regularly,  but  not  always,  only 
part  of  an  acute  general  tuberculosis  with  similar  lesions  in  many 
different  parts  of  the  body. 

Causes. — The  children  affected  are  usually  under  five  years  of 
age.  There  is  often  a  family  history  of  tubercular  disease.  The 
meningitis  is  regularly  only  one  of  the  lesions  belonging  to  an 
acute  general  tuberculosis.  Such  a  general  tuberculosis  may  be 
a  primary  disease,  or  secondary  to  a  localized  tuberculosis. 

Symptoms. — It  is  important  to  remember  that  the  tubercular 
meningitis  is  usually  only  part  of  a  general  tuberculosis,  and  tliat 
the  intensity  of  the  inflammation  of  the  pia  mater  varies  much  in 
different  cases.  So  we  find  that  in  some  cases  the  symptoms  are 
more  like  those  of  a  general  tuberculosis,  in  others  like  those  of 
a  meningitis,  and  that  the  meningitis  may  have  the  characters  of 
an  acute  or  a  sub-acute  inflammation. 

There  may  be  a  prodromic  period,  probably  due  to  the  devel- 
opment of  the  general  tuberculosis,  which  usually  lasts  only  for 
a  few  days,  but  may  be  protracted  for  several  weeks.  During 
this  period  there  are  loss  of  flesh  and  strength,  slight  evening 
fever,  irritability,  sleeplessness,  frontal  headache,  vomiting,  con- 
stipation, and  a  coated  tongue.  These  symptoms  are  not  contin- 
uous, but  are  interrupted  by  periods  of  improvement. 

When  the  disease  is  established  the  child  lies  in  bed,  the  face 
flushed,  in  a  condition  of  alternating  stupor  and  delirium,  either 
one  of  which  may  predominate.     During  the  periods  of  restless- 


THE   PIA   MATER.  21 

ness  the  child  seems  to  have  severe  pain  in  the  head  ;  tliere  is 
photophobia  and  hyperaesthesia  of  the  skin.  There  is  often  fre- 
quent and  active  vomiting.  The  child  rolls  its  head,  moans  and 
cries  out,  it  may  be  actively  delirious,  there  may  be  one  or  more 
general  convulsions.  During  the  period  of  stupor  it  lies  quietly 
in  bed,  taking  no  notice,  but  apparently  placid  and  comfortable. 
The  bowels  are  constipated.  The  pulse  is  slow,  in  proportion  to 
the  temperature,  but  irregular.  The  breathing  also  is  irregular. 
There  is  a  febrile  movement  which  runs  a  very  irregular  course, 
but  is  not  necessarily  at  any  time  very  high.  The  urine  is  scanty 
and  contains  albumin. 

At  the  end  of  the  first  week,  or  a  little  earlier  or  later,  strabis- 
mus, inequality  of  the  pupils,  and  ptosis  are  developed. 

In  the  second  week  the  stupor  deepens  into  coma,  which  may 
be  continuous  or  alternate  with  active  delirium.  The  head  is 
drawn  back,  there  are  convulsive  movements,  or  paralysis,  or 
rigidity  of  the  limbs  and  face,  which  may  be  transient  or  perma- 
nent. There  may  be  automatic  movements  of  the  arms  and  legs. 
The  patients  constantly  pick  at  tjie  nose  and  lips.  The  pupils 
are  dilated,  and  vision  is  lost.  The  pulse  becomes  very  rapid  and 
feeble.  The  course  of  the  disease  is  interrupted  by  short  periods 
of  improvement  ;  it  lasts  for  from  two  to  four  weeks.  The  pa- 
tients die  in  an  attack  of  convulsions,  or  they  become  very  feeble 
and  emaciated  ;  the  urine  is  suppressed,  the  pulse  and  breath- 
ing are  very  rapid,  the  temperature  remains  high,  or  falls  below 
the  normal.  This  is  the  history  of  the  cases  with  general  tuber- 
culosis and  a  moderate  meningitis. 

With  a  more  intense  meningitis  the  cerebral  symptoms  are 
more  active,  the  temperature  is  higher,  and  the  disease  runs  its 
course  within  a  week. 

If  the  meningitis  is  confined  to  the  convexity  of  the  brain  there 
is  no  strabismus  and  little  vomiting.  The  headache,  delirium, 
convulsions,  and  rigidity  of  the  muscles  are  the  chief  symptoms. 
The  disease  runs  its  course  within  a  week. 

T7-eatment. — The  treatment  varies  with  the  acuteness  of  the 
meningitis.  In  cases  which  run  an  active  course,  like  that  of 
an  acute  meningitis,  we  employ  the  same  methods  of  treatment 
as  for  that  disease.  In  the  cases  which  behave  more  like  general 
tuberculosis  with  subacute  cerebral  symptoms,  the  nursing,  feed- 
ing, and  alleviation  of  symptoms  constitute  the  entire  treatment. 

As  a  rule,  the  patients  do  not  recover,  but  from  time  to  time 


2  2:-  THE   PI  A   MATER. 

we  see  cases  which  behave  like  tubercular  meningitis  and  yet  do 
recover.  Whether  in  these  cases  the  meningitis  really  is  tuber- 
cular it  is  impossible  to  say, 

2.  Tubercular  MeninCxItis  in  Adults. — The  changes  in  the  pia 
— the  combinations  of  tubercular,  exudative,  and  cellular  inflam- 
mation— are  the  same  as  in  children.  There  is,  however,  one  im- 
portant difference  between  adults  and  children.  In  children  the 
inflammation  of  the  ependyma  of  the  ventricles,  the  distention  of 
the  ventricles  with  serum,  and  the  consequent  compression  of  the 
brain  are  the  rule  ;  while  in  adults  they  are  the  exception. 

In  adults,  as  in  children,  the  tubercular  meningitis  may  only 
be  part  of  a  general  tuberculosis.  But  more  frequently  it  occurs 
as  a  localized  tubercular  inflammation,  either  primary  or  second- 
ary to  a  localized  tubercular  inflammation  of  some  other  part  of 
the  body. 

Causes. — The  greatest  liability  to  the  disease  seems  to  be 
between  the  ages  of  fifteen  and  twenty-five  years.  Persons  who 
inherit  the  tubercular  disposition,  or  who  have  chronic  pulmonary 
phthisis,  are  especially  liable  tg*  the  disease.  It  may  very  well 
happen  that  the  pulmonary  lesion  is  small  and  insignificant. 

Symptoms. — It  is  convenient,  in  describing  the  symptoms  of 
tubercular  meningitis  in  adults,  to  divide  the  cases  into  three 
clinical  groups  : 

.  (i)  Cases  of  acute  general  tuberculosis  with  tubercular  men- 
ingitis, but  without  the  symptoms  of  meningitis.  The  history  of 
these  patients  belongs  to  general  tuberculosis. 

(2)  Cases  with  well-marked  symptoms  of  meningitis,  which 
come  on  more  or  less  suddenly,  and  are  developed  in  persons 
whose  health  was  apparently  good  up  to  the  time  of  the  attack. 
Of  these  cases  there  are  a  number  in  which  a  localized  tubercu- 
losis has  existed  in  some  part  of  the  body,  but  has  given  so  little 
trouble  that  it  has  not  been  recognized,  so  that  when  the  second- 
ary meningitis  is  developed  it  seems  to  be  a  primary  inflamma- 
tion. In  other  cases,  however,  the  meningitis  is  a  primary,  local- 
ized, tubercular  inflammation. 

In  all  these  cases  the  invasion  of  the  symptoms  may  be  sud- 
den or  gradual.  If  it  is  sudden  there  are  chill,  fever,  headache, 
vomiting,  and  so  much  prostration  that  the  patient  is  at  once 
confined  to  bed.  If  it  is  gradual  the  patients  do  not  feel  sick 
enough  to  go  to  bed  for  several  days.  They  have  a  little  fever, 
headache,  loss  of  appetite,  and  general  malaise. 


THE   PI  A    MATER.  23 

Wlien  the  disease  is  fairly  established  the  lieadache  is  severe 
and  continuous.  The  patients  are  sleepless,  restless,  and  go  on 
to  mild  or  active  delirium.  The  delirium  alternates  witli  stupor, 
or  coma.  There  are  conjunctivitis,  photophobia,  ptosis,  strabis- 
mus, involuntary  ccjntiactions  of  the  muscles  of  the  face,  arms, 
and  legs.  From  two  to  five  days  before  death  there  may  be  per- 
manent hemiplegia,  monoplegia,  or  facial  paralysis.  Hyperaesthe- 
sia  of  the  skin  is  present  in  some  cases.  Vomiting  is  often  per- 
sistent and  troublesome.  A  few  days  before  death  there  may  be 
difficulty  in.  swallowing.  In  some  cases  there  is  pain  and  con- 
traction in  the  muscles.  The  urine  contains  albumin  and  casts. 
The  temperature  may  run  low  or  higli,  and  follows  a  very  irregu- 
lar course.  Generally  speaking,  the  cases  of  short  duration 
have  high  temperatures,  and  those  of  long  duration  low  tem- 
peratures. The  pulse  is  irregular,  sometimes  slow,  sometimes 
rapid. 

The  symptoms  may  be  intense,  continuous,  and  the  patients 
die  in  from  seven  to  fourteen  days  ;  or  they  may  be  less  severe, 
with  intervals  of  improvement,  and  the  patients  may  go  on  for 
from  thirty  to  fifty  days. 

(3)  Cases  with  a  well-marked  history  of  pulmonary  phthisis 
may  at  some  time  develop  the  symptoms  of  tubercular  menin- 
gitis. 

The  prognosis  of  tubercular  meningitis  in  the  adult  is  regu- 
larly bad,  but  yet  we  see  patients  with  characteristic  symptoms 
of  the  disease  who  recover. 

Treatment. — ^The  indications  for  treatment  are  the  same  as  in 
the  tubercular  meningitis  of  children. 

Inflammation  of  the  Cerebral  Arteries. 

The  arteries  throughout  the  body  are  frequently  the  seat  of 
chronic  inflammation. 

In  the  cerebral  arteries  the  ordinary  changes  are  as  follows  : 

1.  There  is  an  increase  in  tlie  size  and  number  of  the  endo- 
thelial cells.  This  is  best  seen  in  the  small  arteries  surrounded 
by  miliary  tubercles,  or  by  small  gummata. 

2.  There  is  a  growth  of  new  connective  tissue,  apparently 
originating  in  the  endothelium,  which  narrows  the  lumen  of  the 
artery  and  may  finally  occlude  it.  The  growth  is  composed  of 
branching    cells,    small    round    cells,  and    basement    substance  ; 


24  THE   PIA   MATER. 

later  the  cells  become  smaller  and  less  numerous,  the  basement 
substance  denser. 

The  growth  forms  a  ring  on  the  inside  of  the  intima  which  is 
not  symmetrical,  but  is  thicker  in  some  places  than  in  others. 
This  is  often  called  obliterating  endarteritis. 

3.  There  is  a  thickening  of  the  inner  coat  beneath  the  endo- 
thelium. The  change  begins  by  a  growth  of  cells  and  a  split- 
ting up  of  the  basement  substance  in  the  intima  immediately 
beneath  the  endothelium.  Then  there  is  a  growth  of  basement 
substance  with  but  few  cells,  which  renders  the  inner  coat 
thicker  and  thicker  until  the  lumen  of  the  artery  is  considerably 
narrowed.  These  changes  may  occur  by  themselves  or  there 
may  be,  in  addition,  thickening  of  the  muscular  and  outer  coats, 
replacement  of  the  muscular  coat  by  dense  connective  tissue, 
thinning  of  portions  of  the  arterial  wall  and  irregular  dilatations, 
deposition  of  the  salts  of  lime  in  the  new  tissue. 

As  a  result  of  these  changes  the  arteries  are  rendered  very 
irregular  channels  for  the  passage  of  the  blood — narrowed  in 
some  places,  dilated  in  others,  or  completely  occluded.  The 
blood-supply  of  the  corresponding  portions  of  the  brain  is  vari- 
able or  cut  ofif  altogether. 

The  diseased  arteries  may  rupture,  with  extravasations  of 
blood.  Portions  of  the  brain  may  become  softened  from  the  oc- 
clusion or  thrombosis  of  the  arteries.  Either  small  or  large 
aneurisms  may  be  formed. 

The  changes  may  be  confined  to  the  larger  arteries  at  the 
base  of  the  brain,  or  they  may  involve  nearly  all  the  branches  of 
the  cerebral  arteries. 

Marked  cerebral  SN^mptoms  are  seen  during  life  in  persons  in 
whom  after  death  no  changes  are  found  in  the  brain,  nothing 
can  be  made  out  except  the  endarteritis. 

Thei^e  may  be  similar  changes  in  the  arteries  in  other  parts 
of  the  body,  or  the  cerebral  arteries  are  the  only  ones  affected. 

Causes. — Chronic  endarteritis  is  especially  common  in  per- 
sons over  forty  years  old.  It  is  frequently  associated  with 
chronic  gout,  constitutional  syphilis,  pulmonary  emphysema, 
chronic  Bright's  disease,  and  chronic  endocarditis.  But  it  may 
also  occur  by  itself  and  without  discoverable  cause. 

The  symptoms  presented  by  these  patients  are  at  first  in  the 
form  of  temporary  attacks,  which  last  for  hours  or  days,  and 
then  disappear.     Such  attacks  are  repeated  at  irregular  intervals 


THE   BRAIN.  2$ 

during  months  or  years,  the  patient  presenting  few  or  no  cere- 
bral symptoms  during  the  intervals.  As  time  goes  on  the 
attacks  become  more  severe  and  more  frequent.  It  is,  however, 
possible  for  the  patient  to  die  during  the  first  attack. 

The  temporary  attacks  are  not  all  of  the  same  character. 
There  may  be  only  headache,  or  anxiety,  restlessness,  and  insom- 
nia, or  vertigo,  or  aphasia,  or  hemianopia,  or  loss  of  conscious- 
ness, or  general  convulsions,  or  spasmodic  contractions  of  groups 
of  muscles,  or  paralysis  of  one  arm,  of  one  leg,  or  of  the  whole 
of  one  side  of  the  body,  or  loss  of  sensation  in  different  areas  of 
the  skin. 

The  first  attack  may  prove  fatal,  but  the  patient  often  con- 
tinues to  live  for  months  or  years.  Even  after  recovering  from 
the  first  attack,  however,  there  is  a  perceptible  change  in  the 
patient's  mental  and  bodily  condition,  sometimes  very  marked. 
The  attacks  are  repeated  until  finally  the  patient  develops  the 
symptoms  of  chronic  meningitis,  or  becomes  completely  hemi- 
plegic,  or  dies  with  general  convulsions  or  coma. 

Treat7nent. — Apart  from  antisyphilitic  treatment  in  the  proper 
cases,  the  most  important  points  to  enforce  are  abstinence  from 
all  alcoholic  drinks,  and  exercise  in  the  open  air. 

The  Ventricles  of  the  Brain. 

Inflammations  of  the  pia  mater  are  often  accompanied  by 
lesions  of  the  A'entricles  of  the  brain.  Less  frequently  we  find 
lesions  of  the  ventricles  occurring  by  themselves,  with  little  or 
no  change  in  the  pia  mater.     We  distinguish  : 

Acute  ependymitis. 

Acute  dilatation  of  the  ventricles  in  adults. 

The  chronic  hydrocephalus  of  children. 

Chronic  hydrocephalus  due  to  injuries,  or  secondary  to  men- 
ingitis. 

I.  Acute  Ependymitis. — Of  this  v^e  find  two  varieties  :  an 
acute  and  a  subacute  form. 

In  the  acute  form  w^e  find  the  ependyma  congested,  infiltrated 
with  pus-cells,  and  coated  with  a  layer  of  fibrin  and  pus.  The 
ventricles  contain  purulent  serum. 

The  patients  exhibit  a  decided  febrile  movement,  general 
convulsions,  alternating  stupor  and  delirium,  local  paralysis,  and 
finally  coma.     The   disease  runs    its  course  within   a  few  days. 


26  THE   BRAIN. 

The  symptoms  resemble  those  of  an  acute  tubercular  menin- 
gitis. 

So  few  of  these  cases  have  been  observed  that  we  are  igno- 
rant of  the  prognosis. 

The  treatment  would  seem  to  be  the  same  as  that  for  acute 
meningitis. 

In  the  subacute  form  the  ventricles  are  dilated  and  full  of 
serum.  The  ependyma  is  thickened,  the  endothelial  cells  on  its 
surface  are  multiplied,  and  there  is  a  growth  of  cells  around  the 
blood-vessels. 

The  patients  have  headache  ;  vomiting  ;  at  first  photophobia, 
later  dilated  pupils  ;  hyperaesthesia  of  the  skin  ;  an  irregular 
rise  of  temperature,  never  very  high,  and  sometimes  below  the 
normal  ;  finally  coma.  The  disease  lasts  for  weeks  or  months. 
The  symptoms  resemble  those  of  a  subacute  tubercular  menin- 
gitis. 

These  cases  again  are  so  seldom  recognized  that  we  do  not 
know  how  many  of  them  may  recover. 

2.  Acute  Dilatation  of  the  Ventricles  in  Adults — Serous 
Apoplexy. — Lesions. — Either  one  lateral  ventricle,  or  botli,  or  all 
the  ventricles  are  dilated  and  filled  with  clear  serum.  The 
ependyma  is  white,  somewhat  thickened,  its  surface  smooth  or 
finely  granular.  The  convolutions  of  the  hemispheres  are  some- 
what flattened. 

Causes. — The  disease  is,  in  New  York,  not  an  uncommon  one. 
It  occurs  both  in  strong  and  vigorous  adults  and  in  persons  who 
have  suffered  from  chronic  diseases.  In  some  persons  there  is  a 
previous  history  of  injuries  to  the  head,  or  of  mental  or  bodily 
overwork.  In  som.e  cases  the  condition  is  complicated  by  chronic 
endarteritis,  or  chronic  meningitis.  It  is  said  that  there  may  be 
an  obstruction  of  the  veins  or  of  the  passages  between  the  ven- 
tricles. 

The  disease  may  be  confounded  with  cerebral  apoplexy,  em- 
bolism, chronic  endarteritis,  or  tumors  of  the  brain. 

Syjnptoms. — The  patients  suffer  from  headache,  noises  in  the 
ears,  loss  of  memory,  dulness  of  the  mental  faculties,  slowness  of 
speech,  sleeplessness,  disturbed  digestion,  sometimes  temporary 
aphasia,  or  local  paralysis.  Tliese  symptoms  may  only  last  for  a 
few  hours,  or  they  may  continue  for  a  number  of  weeks.  At  the 
end  of  this  time  some  of  the  patients  recover  completely. 

Others,  however,  either  rapidly  or  gradually  pass  into  the  con- 


THE   BRAIN.  27 

dition  of  complete  coma.  In  this  condition  they  remain  for  a 
few  days  and  then  die,  the  temperature  rising  before  deatli. 

Others,  on  the  contrary,  develop  an  active  delirium,  blind- 
ness, internal  strabismus,  convulsive  movements  of  groups  of 
muscles,  a  febrile  movement,  and  finally  become  comatose. 

Treatment. — Recoveries  from  the  disease  are  reported  after 
treatment  with  mercury  and  potassium  iodide. 

3.  The  Chronic  Hydrocephalus  of  Children. — Lesions. — 
There  is  an  accumulation  of  serum  in  the  ventricles  of  the  brain, 
so  large  in  quantity  that  the  brain  is  thinned,  the  dura  mater 
stretched,  and  the  cranial  bones  separated  from  eacli  other.  The 
ependyma  appears  to  be  normal,  or  is  somewhat  thickened. 

Causes. — We  are  ignorant  of  the  causes  of  this  lesion.  It 
seems  to  begin  during  intra-uterine  life.  It  may  reach  a  consid- 
erable development  before  birth,  or  remain  latent  for  months  or 
years  after  birth. 

Symptons. — If  the  disease  is  so  much  developed  during  intra- 
uterine life  that  the  large  head  prevents  the  birth  of  the  child, 
craniotomy  must  necessarily  be  performed. 

If  the  disease  is  moderately  developed  during  intra-uterine 
life,  the  child  can  be  born  alive.  But  it  is  at  once  evident  that 
the  head  is  too  large  ;  the  child  does  not  perform  its  functions 
well,  and  dies  in  a  short  time. 

In  many  cases,  at  the  time  of  birth  the  child  shows  no  evi- 
dences of  the  disease,  and  it  is  not  till  after  months  or  years  that 
its  symptoms  are  developed.  Of  these  later  developed  cases  we 
may  distinguish  a  mild  and  a  severe  form  of  the  disease. 

In  the  mild  cases  the  head  is  usually  large,  the  fontanelles 
and  sutures  open,  the  face  small.  The  intelligence  remains  good. 
From  time  to  time,  for  periods  of  several  days,  the  child  suffers 
from  disturbances  of  digestion  and  nutrition,  a  febrile  move- 
ment, fits  of  crying,  restlessness,  and  drowsiness. 

In  these  mild  cases  the  disease  is  not  of  itself  fatal,  but  the 
children  are  apt  to  be  carried  off  by  some  of  the  diseases  of 
childhood. 

In  the  severe  cases  there  is  marked  impairment  of  nutrition  ; 
the  children  are  dull  and  stupid,  irritable  and  drowsy  ;  there  are 
often  strabismus,  nystagmus,  dilated  pupils,  protruded  eyeballs, 
blindness,  deafness,  general  convulsions,  and  paraplegia.  There 
may  be  a  febrile  movement.  These  symptoms  are  interrupted 
by  periods  of  improvement,  but  the  course  of  the  disease  is  usu- 


28  THE   BRAIN. 

ally  downward,  and  the  children  die  in  an  attack  of  convulsions, 
or  of  inanition,  or  from  some  intercurrent  disease.  Rarely  they 
grow  up  to  adult  life,  but  remain  more  or  less  idiotic. 

The  treattnent  is  mainly  directed  to  the  general  condition  of 
the  patient.  Careful  feeding,  a  clean  skin,  good  air,  the  admin- 
istration of  iron  and  of  cod-liver  oil  are  the  essentials.  During 
the  exacerbations  of  the  symptoms  the  iodide  of  potash  may  be 
of  service. 

4.  Chronic  Hydrocephalus  in  Older  Children. — In  older 
children  and  in  adolescents  we  meet  with  cases  of  chronic  hydro- 
cephalus, not  congenital,  but  occurring  after  meningitis,  after 
injuries,  and  without  discoverable  cause. 

In  some  cases  of  acute  meningitis,  the  patient,  after  going 
through  the  symptoms  of  this  disease  and  beginning  to  improve, 
makes  only  an  attempt  at  convalescence,  again  becomes  worse, 
is  alternately  delirious  and  stupid,  has  a  moderate  febrile  move- 
ment, and  emaciates.  After  continuing  in  this  condition  for 
weeks,  he  may  recover  or  die. 

In  the  cases  which  occur  after  injury  and  without  discovera- 
ble cause,  the  clinical  history  is  like  that  of  the  chronic  hydro- 
cephalus of  young  children,  but  without  the  enlargement  of  the 
head. 


THE    PHARYNX    AND   TONSILS. 


The  nose,  the  pharynx,  and  the  mouth  are  lined  with  a  contin- 
uous tract  of  mucous  membrane,  which,  on  account  of  its  situa- 
tion, exposed  to  a  great  variety  of  irritants,  is  very  often  the  seat 
of  acute  and  chronic  inflammations.  The  chronic  inflammations 
are  best  treated  by  the  specialist  ;  the  acute  inflammations  are 
usually  left  in  the  hands  of  the  general  practitioner. 

Throughout  this  whole  tract  the  structure  of  the  mucous 
membrane  is  essentially  the  same — an  outer  covering  of  epithe- 
lium, a  vascular  stroma,  a  large  supply  of  mucous  glands. 

On  each  side  of  the  pharynx  is  a  lymphatic  gland  of  some 
size  — the  tonsil.  The  shape  of  the  tonsils  is  peculiar;  it  is  that 
of  a  flat  mass  of  lymphatic  glandular  tissue  folded  on  itself  so  as 
to  form  a  wrinkled  ovoid  body,  of  which  the  outer  surface  is  cov- 
ered with  a  layer  of  epithelium.  The  wrinkles  are  the  crypts  of 
the  tonsils. 

We  will  consider  : 

Acute  catarrhal  pharyngitis. 

Acute  tonsillitis. 

Acute  croupous  tonsillitis. 

Suppurative  tonsillitis. 

Acute  Catarrhal  Pharyngitis. 

This  is  a  simple,  acute,  exudative  inflammation  which  involves 
circumscribed  portions  of  the  pharynx,  or  the  entire  throat  with 
the  tonsils,  or  extends  also  into  the  nose. 

Lesions. — Tlie  mucous  membrane  is  congested  and  swollen. 
The  function  of  the  mucous  glands  is  at  first  arrestedj  so  that  the 
surface  of  the  mucous  membrane  is  dry  ;  after  some  hours  or 
days  the  function  of  these  glands  is  stimulated.  There  is  then 
an  increased  quantity  of  mucus,  which   is  thin  and   easily  dis- 


30  THE   PHARYNX   AND   TONSILS. 

charged  from  the  surface  of  the  mucous  membrane,  or  thick  and 
tenacious,  so  that  it  adheres  to  it. 

Causes. — Some  individuals,  and  the  members  of  some  families, 
are  especially  liable  to  acute  pharyngitis  ;  this  liability  is  most 
marked  in  young  people.  The  inhalation  of  irritating  gases,  or 
of  irritating  substances  floating  in  the  air,  is  a  frequent  cause  of 
pharyngitis.  Prolonged  exposure  to  cold  and  wet  and  disturb- 
ances of  the  stomach  also  seem  to  be  efficient  causes. 

Symptoms. — The  symptoms  are  constitutional  and  local.  The 
principal  constitutional  symptom  is  a  rise  of  temperature,  with 
the  accompanying  chills,  prostration,  vomiting,  headache,  and 
pains  in  the  limbs.  This  fever  often  precedes  the  sore  throat, 
and  disappears  before  the  latter  has  subsided. 

The  local  symptoms  are  the  characteristic  appearance  of  the 
throat  and  the  pain,  which  is  increased  by  any  movement  of  the 
muscles  of  the  pharynx.  The  pain  is  most  annoying  when  the 
inflammation  involves  the  pillars  of  the  fauces,  the  upper  surface 
of  the  soft  palate,  and  the  uvula. 

The  cases  vary  as  to  the  height  of  the  temperature  and  the 
severity  of  the  constitutional  symptoms.  In  the  worst  cases  the 
temperature  reaches  104°  F.,  and  the  patients  look  seriously  ill. 

The  inflammation  is  a  self-limited  one,  lasting  for  from  four  to 
seven  days,  but  occasionally  it  continues  for  a  longer  time. 

Treatment. — As  the  inflammation  is  a  self-limited  one,  and 
naturally  terminates  in  recovery,  treatment  is  directed  to  short- 
ening its  duration  and  making  the  patient  more  comfortable. 

The  best  local  application  at  the  beginnmg  of  the  disease 
seems  to  be  cocaine  ;  later  the  mild  astringents  are  of  service. 

The  milder  cases  require  nothing  but  the  local  treatment. 
In  the  more  severe  cases  a  variety  of  drugs  are  given  :  opium  in 
small  doses,  calomel  or  the  sulphate  of  magnesia  in  small  doses, 
tincture  of  aconite  in  drop  doses,  salicylate  of  soda  in  doses  of 
ten  to  twenty  grains  every  three  hours,  or  salol  in  the  same 
doses. 

Profuse  sweating  of  the  entire  skin  may  be  of  service. 

Acute  Tonsillitis. 

Synonyms.— Yo\Y\c\x\2,x  tonsillitis,  ulcerative  tonsillitis,  spotted 
sore  throat. 

Lesions. — There  is  a  simple  exudative  inflammation  of  one  or 
both  tonsils.     These  bodies  are  swollen  so  that  thev  can  be  seen 


THE   PHARYNX   AND   TONSILS.  3 1 

projecting  into  the  throat,  and  are  congested.  The  crypts  are 
filled  with  little  Avhite  masses  of  mucus  and  epithelium,  which 
contrast  with  the  congested   tonsils.     There  are  no  real  ulcers. 

The  causes,  symptoms,  and  treatment  of  acute  tonsillitis  are 
the  same  as  those  of  acute  pharyngitis. 

Croupous  Tonsillitis. 

SynoJiym. — Diphtheritic  sore  throat. 

Lesions. — The  tonsils  are  congested  and  swollen.  Their  sur- 
faces are  partly  or  completely  covered  with  patches  of  false 
membrane.  The  false  membrane  is  composed  of  fibrin,  pus,  and 
necrotic  epithelium.  The  stroma  of  the  mucous  membrane  is 
infiltrated  with  fibrin  and  pus.  The  lymphatic  glands  in  the  neck 
may  be  swollen. 

In  bad  cases  there  is  gangrene  of  portions  of  the  tonsils  and 
of  the  tissues  of  the  neck. 

Streptococci  and  staphylococci  are  found  in  the  inflamed  tis- 
sues and  the  false  membrane. 

Causes. — This  form  of  tonsillitis  is  due  to  local  infection  with 
streptococci  and  staphylococci.  It  is  a  complication  of  many  of 
the  infectious  diseases,  but  especially  of  scarlet  fever.  Less  fre- 
quently it  occurs  by  itself. 

Symptoms. — A  croupous  tonsillitis  gives  the  same  symptoms 
as  does  a  simple  tonsillitis,  but  much  more  severe. 

The  temperature  is  higher,  the  prostration  greater,  the  ap- 
pearance of  the  inflamed  tonsils  is  quite  different.  The  inflam- 
mation regularly  runs  its  course  within  a  week,  but  the  prostra- 
tion left  after  the  disease  is  more  marked  and  lasts  longer. 

The  gangrenous  forms,  however,  are  attended  with  septic 
symptoms,  and  are  usually  fatal. 

Treatment. — The  most  efficient  treatment  is  the  frequent  and 
thorough  local  application  of  large  quantities  of  weak  solutions 
of  bichloride  of  mercury,  or  peroxide  of  hydrogen. 

Suppurative  Tonsillitis. 

Synonym. — Quinsy  sore  throat. 

Lesions. — There  is  in  one  or  both  tonsils  an  acute  exudative 
inflammation  with  necrosis  of  tissue,  which  goes  on  to  the  for- 
mation of  an  abscess  in  the  substance  of  the  tonsil.  A  catarrhal 
pharyngitis  accompanies  tlie  tonsillitis. 


32  THE   PHARYNX   AND   TONSILS. 

Causes. — There  is  a  decided  predisposition  in  some  persons 
and  in  some  families  to  this  form  of  tonsillitis.  Apparently,  the 
exciting  causes  are  the  same  as  for  simple  tonsillitis,  with  the  ad- 
dition of  the  bacteria  of  suppuration. 

Symptoms. — There  is  a  febrile  movement  which  precedes  and 
accompanies  the  tonsillitis.  Accompanying  the  fever  are  chills, 
headache,  vomiting,  pains  in  the  back,  and  prostration. 

The  inflamed  tonsil  becomes  gradually  more  and  more  swol- 
len, it  fills  up  the  pharynx,  pushes  the  soft  palate  forward,  and. 
projects  outward  into  the  neck.  From  the  beginning  there  is  a 
good  deal  of  pain  in  the  throat,  and,  as  the  swelling  increases, 
the  pain  is  greater,  the  mouth  and  throat  are  constantly  filled 
with  mucus  and  saliva.  The  patients  can  hardly  swallow  any- 
thing, they  feel  as  if  they  might  suffocate,  they  are  unable  to 
sleep.  If  both  tonsils  are  inflamed  and  the  uvula  swollen,  or  if 
there  is  oedema  of  the  glottis,  there  is  real  danger  of  suffocation. 
All  the  symptoms  continue  and  increase  until  the  abscess  breaks 
and  the  pus  is  discharged.  Then  there  is  an  abrupt  change  for 
the  better,  and  in  a  few  days  the  patient  is  well. 

The  inflammation  regularly  runs  its  course  and  terminates 
in  rupture  of  the  abscess  within  a  week.  If  both  tonsils  are  in- 
flamed successively  the  disease  lasts  longer. 

The  patients  almost  uniformly  recover,  but  it  is  possible  for 
death  to  be  produced  by  oedema  of  the  glottis. 

Treatment. — During  the  first  twenty-four  hours  of  the  tonsilli- 
tis we  may  try  to  abort  the  inflammation  bv  the  use  of  calomel, 
sulphate  of  magnesia,  aconite,  salicylate  of  soda,  salol,  or  cold 
applied  to  the  neck. 

After  the  abscess  has  been  formed,  the  inhalation  of  hot 
steam  and  the  application  of  moist  heat  to  the  neck  are  of  ser- 
vice. The  excessive  production  of  mucus  can  be  partly  con- 
trolled by  astringent  washes  and  the  administration  of  belladon- 
na. The  pain  and  distress  can  be  alleviated  by  local  applications 
of  cocaine  and  the  internal  use  of  opium. 

Swelling  of  the  uvula  and  oedema  of  the  glottis  demand  free 
scarification. 


THE    LARYNX. 


Laryngismus   Stridulus. 

This  name  is  given  to  two  different  forms  of  spasmodic  con- 
traction of  the  muscles  of  the  larynx. 

1.  There  is  a  spasmodic  closure  of  the  glottis,  which  is  almost 
complete,  lasts  for  a  few  seconds,  and  is  then  followed  by  a  loud, 
stridulous  inspiration. 

This  occurs  in  young  children,  usually  under  two  years  of 
age,  who  are  badly  nourished,  or  who  suffer  from  rickets. 

It  occurs  in  attacks,  which  are  repeated  after  short  or  long 
intervals. 

The  child  suddenly  stops  breathing,  the  face  and  lips  become 
pale,  or  slightly  livid,  the  appearance  is  almost  that  of  a  dead 
person.  Then,  after  a  few  seconds,  there  is  a  long,  stridulous 
inspiration,  and  the  attack  is  over.  Sometimes  the  attacks  are 
accompanied  by  rigidity  of  the  muscles,  or  by  general  convul- 
sions, or  by  unconsciousness.     Occasionally  the  attacks  are  fatal. 

At  the  time  of  an  attack,  if  it  is  an  alarming  one,  we  may  give 
inhalations  of  nitrite  of  amyl,  or  pass  a  tube  through  the  larynx. 

To  prevent  the  attacks  the  nutrition  of  the  child  is  to  be  im- 
proved in  every  possible  way. 

2.  There  is  a  spasmodic  partial  closure  of  the  glottis,  attended 
with  difficult  and  stridulous  breathing,  which  lasts  for  several' 
hours. 

This  occurs  in  young  children  of  all  kinds,  whether  their  pre- 
vious health  has  been  good  or  not.  There  is  a  decided  predis» 
position  in  families  and  in  individuals.  Some  of  the  attacks  are 
due  to  indigestion,  for  others  no  cause  can  be  discovered. 

The  attacks  usually  begin  in  the  night  and  last  until  the  next 
day.  The  child  wakes  up  in  the  night  with  laryngeal  dyspnoea, 
which  after  a  time  is  followed  by  more  or  less  venous  congestion 
of  the  skin.     But  there  is  no  fever,  and,  except  for  the  dyspnoea, 


34  THE   LARYNX. 

the  child  does  not  look  ill.  Although  the  dyspnoea  may  appear 
alarming,  it  always  eventually  subsides,  even  if  it  is  left  to  itself  ; 
but  an  emetic  will  cause  it  to  disappear  more  rapidly.  The  best 
emetics  are  those  which  act  the  quickest  ;  the  yellow  sulphate  of 
mercury,  apomorphia,  ipecac,  and  antimony  are  those  ordinarily 
used. 

Acute  Catarrhal  Laryngitis. 

Lesiojis. — The  mucous  membrane  of  the  larynx  is  congested, 
and  at  first  dry.  The  stage  of  dryness  lasts  for  from  twelve  to 
forty-eight  hours,  and  is  then  succeeded  by  an  increased  produc- 
tion of  mucus.  With  the  production  of  the  mucus  the  conges- 
tion and  swelling  of  the  mucous  membrane  diminish.  The  in- 
flammation may  extend  to  the  trachea  and  bronchi  or  to  the 
pharynx.     It  occurs  both  in  adults  and  children. 

1.  In  Adults.  Causes. — The  inflammation  occurs  without  dis- 
coverable cause,  after  exposure  to  cold,  from  the  inhalation  of 
smoke  or  steam,  with  syphilis,  phthisis,  measles,  scarlatina,  vari- 
ola, erysipelas,  typhus  and  typhoid  fevers. 

Symptoms. — In  the  more  severe  cases  there  is  a  febrile  move- 
ment, in  the  milder  cases  this  is  absent. 

The  patients  have  a  laryngeal  cough,  at  first  dry,  afterward 
with  mucous  expectoration.  The  voice  is  husky,  or  stridulous, 
or  reduced  to  a  whisper.  There  is  more  or  less  discomfort  or 
pain  in  the  larynx.  In  some  of  the  cases  there  is  laryngeal  dysp- 
noea, continuous,  but  with  exacerbations.  The  most  alarming 
feature  about  this  dyspnoea  is  that  occasionally  the  patients  stop 
breathing  suddenly  and  die. 

The  inflammation  usuall)'  runs  its  course  within  two  weeks, 
but  it  may  be  protracted  for  a  much  longer  period. 

Treatment. — During  the  acute  stages  of  the  laryngitis  the  con- 
tinuous application  of  hot  sponges  to  the  neck,  and  the  inhala- 
tion of  steam,  are  of  decided  service.  The  internal  administra- 
tion of  tartarized  antimony,  or  of  the  iodide  of  potash,  may  also 
be  useful.  When  the  dyspnoea  is  urgent  the  patients  are  to  be 
constantly  "^'■atched,  in  order  that  intubation  or  tracheotomy  may 
be  performed,  if  necessary.  If  the  inflammation  is  prolonged 
the  mineral  acids,  quinine,  iron,  and  change  of  climate  may  hast- 
en the  subsidence  of  the  disease.  The  local  application  of  as- 
tringent sprays  is  of  much  service. 

2.  In  Children. — The  catarrhal  laryngitis  of  children  is  often 


THE   LARYNX.  35 

called  catarrhal  croup.  It  is  one  of  the  most  common  diseases 
of  childhood. 

It  occurs  often  without  discoverable  cause,  sometimes  after 
exposure  to  cold  and  wet,  from  the  inhalation  of  steam  and 
smoke,  and  as  a  complication  of  measles  and  scarlatina. 

The  disease  is  most  common  in  children  between  the  ages  of 
one  and  five  years,  less  frequent  in  older  children.  There  is  a 
well-marked  predisposition  to  the  disease  in  some  children  and 
in  some  families. 

The  changes  in  the  mucous  membrane  of  the  larynx  are  the 
same  as  those  observed  in  adults,  but  the  smaller  size  of  the  larynx 
in  children  causes  the  swollen  mucous  membrane  to  be  a  still 
greater  obstruction  to  the  act  of  breathing. 

Syrnpto77is. — The  local  symptoms  are  :  Dyspnoea,  which  is  con- 
tinuous, but  with  exacerbations  ;  in  some  cases  attacks  of  laryn- 
gismus stridulus  ;  stridulous  voice  or  loss  of  voice  ;  and  stridulous 
cough. 

The  general  symptom  is  a  rise  of  temperature  with  its  accom- 
panying disturbances.  The  fever  may  precede,  or  follow,  or  be 
simultaneous  with,  the  local  symptoms. 

The  invasion  of  the  disease  is  often  sudden,  and  then  usually 
occurs  in  the  night,  with  the  continuous  dyspnoea,  or  an  attack 
of  laryngismus  stridulus  as  the  first  symptom. 

In  other  cases  the  invasion  of  the  disease  is  gradual,  with  a 
croupy  cough  as  the  first  symptom. 

The  ordinary  cases  last  for  three  days  and  nights,  the  symp- 
toms worse  during  the  night  and  better  during  the  day. 

The  patients  vary  as  to  the  height  of  the  temperature  and  the 
degree  of  the  dyspnoea.  Most  of  the  patients  are  decidedly  better 
by  the  fourth  day,  the  improvement  beginning  with  the  produc- 
tion of  mucus  from  the  inflamed  membranes.  Occasionally,  how- 
ever, the  laryngitis  is  protracted  for  one  or  two  weeks,  or  it  may 
be  succeeded  by  a  bronchitis. 

The  Prognosis  is  good,  even  the  severe  cases  are  seldom  fatal. 

Treatment. — For  the  laryngitis  we  apply  moist  heat  to  the 
neck,  and  give  internally  five-  or  ten-drop  doses  of  the  wine  of 
antimony  every  one  or  two  hours.  For  the  attacks  of  laryngismus 
stridulus  we  give  emetics.  For  the  fever  it  may  be  proper  to  use 
small  doses  of  antifebrin  or  tincture  of  aconite  ;  for  the  restless- 
ness, small  doses  of  opium.  In  the  protracted  cases  small  doses 
of  calomel  may  be  of  service. 


36  THE   LARYNX. 

Croupous  Laryngitis. 

Synonym. — Membranous  croup. 

Lesions. — The  mucous  membrane  of  the  larynx  is  congested, 
swollen,  and  infiltrated  with  fibrin  and  pus.  Its  free  surface  is 
coated  with  a  false  membrane  composed  of  fibrin,  pus,  and  ne- 
crotic epithelium. 

Streptococci  and  staphylococci  are  found  in  the  false  mem- 
brane and  the  inflamed  tissues,  except  in  the  cases  in  which  tlie 
laryngitis  is  caused  by  a  local  irritant. 

Causes. — Children  are  more  liable  to  the  disease  than  are  adults. 
Most  of  the  cases  are  examples  of  a  streptococcus  inflammation 
complicating  measles  and  scarlet  fever.  But  it  may  also  occur 
in  the  same  way  with  the  other  infectious  diseases  and  by  itself. 

A  similar  inflammation  may  be  excited  by  the  inhalation  of 
irritative  vapors,  such  as  hot  steam  or  smoke,  and  by  swallowing 
irritating  fluids  which  find  their  way  into  the  larynx. 

The  Symptotns  are  the  same  as  those  of  a  catarrhal  laryngitis, 
but  are  more  severe,  more  continuous,  and  last  for  a  longer  time. 
The  temperature  is  higher,  the  dyspnoea  is  more  severe,  and  the 
evidences  of  imperfect  aeration  of  the  blood  are  more  marked. 
In  the  favorable  cases,  after  from  four  to  seven  days  the  inflam- 
mation subsides,  the  false  membrane  becomes  loosened,  is  coughed 
up,  and  the  dyspnoea  is  relieved.  In  the  unfavorable  cases  the 
dyspnoea  continues  and  causes  the  death  of  the  patient. 

The  Prognosis  is  unfavorable,  especially  in  children  under  three 
years  of  age. 

The  Treatment  is  the  same  as  that  for  a  catarrhal  laryngitis, 
but  in  addition  it  is  often  necessary  to  employ  intubation  or 
tracheotomy  to  relieve  the  dyspnoea.  The  inhalation  of  the 
fumes  of  calomel  may  be  of  great  service. 


THE    PLEURA. 


In  the  study  and  treatment  of  the  diseases  of  the  pleura  and 
of  the  lungs  we  are  very  much  assisted  by  percussion  and  auscul- 
tation, by  the  aid  of  which  we  determine  the  so-called  physical 
signs. 

The  Physical  Signs  of  the  Pleura  and  of  the  Lungs. 

Percussion. — When  we  percuss  the  wall  of  the  chest  we  obtain 
certain  sounds,  and  of  these  sounds  we  note  the  quality,  the  pitch, 
the  intensity,  and  the  duration. 

1.  Pulmonary  Resonance. — This  is  characterized  by  pulmonary 
quality,  low  pitch,  considerable  duration,  and  variable  intensity. 
It  is  heard  over  the  healthy  lung. 

2.  Dulness. — Of  this  the  quality  is  imperfectly  pulmonary,  the 
pitch  is  higher,  the  duration  is  short,  the  intensity  is  small.  It  is 
heard  over  the  normal  lung  where  the  chest-wall  is  thickened  by 
bone  or  muscle,  and  where  the  liver  and  heart  are  in  contact  with 
the  lung.  It  is  heard  over  pleuritic  adhesions,  over  small  quan- 
tities of  fluid  in  the  pleural  cavities,  over  consolidations  of  the 
lung,  emphysema,  enlargements  of  the  heart,  liver,  and  spleen, 
aneurisms  of  the  aorta,  abscesses,  and  tumors, 

3.  Flatness. — The  quality  is  fiat,  the  pitch  is  high,  the  duration 
is  short,  the  intensity  is  small.  It  is  heard  over  the  liver,  where  it 
is  uncovered  by  the  lung,  over  thick  pleuritic  adhesions,  fluid  in 
the  pleural  cavities,  complete  consolidation  of  the  lung,  aneu- 
risms, abscesses,  tumors,  and  rarely  over  a  lung  which  is  not 
consolidated,  but  of  which  the  bronchi  are  completely  obstructed. 

4.  Tympanitic  Resonance.  — The  quality  is  tympanitic,  the  pitch 
is  high  or  low,  the  duration  is  considerable,  the  intensity  is  marked. 
It  is  heard  over  the  stomach  and  intestines,  over  air  in  the  pleural 
cavities,  over  cavities  in  the  lungs,  over  solidified  and  compressed 
lung,  and  with  emphysema. 


38  THE   PLEURA. 

5.  The  Cracked  Pot  Sound. — The  quality  is  metallic,  the  pitch 
is  high,  the  duration  and  intensity  are  not  very  great.  It  is  heard 
over  cavities,  and  over  consolidated  and  compressed  lung. 

6.  Amphoric  Resonance. — The  quality  is  amphoric,  the  pitch  is 
low,  the  duration  and  intensity  are  considerable.  It  is  heard 
over  air  in  the  pleural  cavity,  over  large  cavities  in  the  lung,  and 
occasionally  over  consolidations  of  the  lower  lobe  of  the  left 
lung. 

The  Breathing. — In  listening  to  the  breathing  we  distinguish 
the  sound  of  inspiration  and  that  of  expiration,  and  of  each  we 
note  the  quality,  the  pitch,  the  intensity,  and  the  duration, 

1.  Pulmonary,  or  Vesicular  Breathing. — Of  inspiration,  the  qual- 
ity is  pulmonary,  the  pitch  is  low,  the  duration  is  considerable, 
the  intensity  is  variable.  Of  expiration,  the  pitch  is  low  and  the 
duration  is  shorter. 

2.  Bronchial  Breathing. — Of  inspiration,  the  quality  is  bron- 
chial, the  pitch  is  high,  the  intensity  and  duration  are  variable. 
Of  expiration,  the  pitch  is  higher  and  the  duration  is  longer  than 
those  of  inspiration.  It  is  heard  over  consolidated  and  com- 
pressed lung,  and  over  cavities. 

3.  Bro7icho-vesicular  Breathing. — This  is  of  a  character  inter- 
mediate between  that  of  vesicular  and  that  of  bronchial  breathing. 
It  is  heard  over  the  normal  lung  in  the  interscapular  region,  and 
over  the  lesser  degrees  of  consolidation  and  compression  of  the 
lung. 

4.  Cavernous  Breathing. — Of  the  inspiration,  the  quality  is 
cavernous,  the  pitch  is  low.  The  expiration  is  longer  and  lower- 
pitched  than  the  inspiration.  It  is  heard  over  cavities  and  over 
consolidated  or  compressed  lung. 

5.  Amphoric  Breathing. — The  quality  is  amphoric,  the  pitch  is 
low,  the  expiration  is  prolonged.  It  is  heard  over  large  cavities 
in  the  lungs,  and  over  pleural  cavities  which  contain  air,  with 
perforation  of  the  lung. 

6.  Sibilant  Breathing. — The  quality  is  sibilant,  the  pitch  is 
high,  the  intensity  is  great,  the  expiration  is  prolonged. 

Sonorous  Breathing. — The  quality  is  sonorous,  the  pitch  is  low, 
the  intensity  is  great,  the  expiration  is  prolonged.  Both  these 
forms  of  breathing  are  produced  by  a  contraction  of  the  calibre 
of  the  larger  and  medium-sized  bronchi.  The  ordinary  causes 
of  such  a  contraction  are  bronchitis  and  spasmodic  asthma. 

A  special  form  of  sibilant  and  sonorous   breathing  is  pro- 


THE   PLEURA.  39 

duced  by  narrowing  of  the  lumen  of  the  trachea,  or  of  the  large 
bronchi. 

Rales. — These  are  abnormal  sounds  which  accompany  the 
breathing  and  are  not  heard  over  the  healthy  lung. 

1.  The  Crepitant  Rale. — This  is  a  very  fine,  dry,  crackling 
sound.  It  is  heard  at  the  end  of  inspiration,  is  produced  in 
puffs,  and  seems  to  be  close  to  the  ear.  It  is  heard  with  dry 
pleurisy,  with  pneumonia,  and  with  phthisis. 

2.  The  Subcrepitant  Rale. — This  is  a  fine,  moist  sound  ;  heard 
with  inspiration,  or  with  expiration,  or  with  both.  It  accom- 
panies dr}^  pleurisy,  bronchitis,  pneumonia,  phthisis,  and  oedema 
of  the  lungs. 

3.  The  Coarse,  or  Mucous,  Rales. — These  are  loud,  moist 
sounds,  heard  both  with  inspiration  and  expiration.  They  are 
heard  with  pleurisy,  with  bronchitis,  with  pneumonia,  and  with 
phthisis. 

4.  The  Gurgling  Rales. — These  are  loud,  coarse,  moist  sounds, 
of  gurgling  quality.  They  are  heard  over  small  cavities,  over 
compressed  lung,  and  occasionally  over  pleuritic  adhesions. 

Friction  Sounds. — These  are  produced  by  the  rubbing  of  op- 
posed surfaces  of  pleura  coated  with  fibrin,  or  by  the  movement 
of  pleuritic  adhesions. 

They  have  the  characters  of  the  crepitant,  the  subcrepitant, 
the  mucous,  or  the  gurgling  rale  ;  the  sound  is  a  grazing,  or 
rubbing,  or  creaking  one. 

The  Voice. —  The  Pulmonary  Voice. — The  quality  is  pulmo- 
nary, the  pitch  is  low,  the  intensity  and  the  thrill  differ  with  the 
individual. 

Increased  Vocal  Resonance. — The  quality  is  pulmonary,  the 
pitch  is  higher,  the  intensity  and  the  thrill  are  greater.  It  is 
heard  over  the  normal  lung  in  the  right  infra-clavicular  and  in 
both  the  interscapular  regions.  It  is  also  heard  over  consoli- 
dated or  compressed  lung,  over  cavities,  and  over  lung  which  is 
adherent  to  the  wall  of  the  chest. 

Diminished  Vocal  Resonance. — The  intensity  and  the  thrill  are 
diminished,  the  quality  and  the  pitch  are  the  same  as  with  the 
pulmonary  voice.  It  is  heard  over  small  effusions  in  the  pleural 
cavities,  over  thick  pleuritic  adhesions,  over  consolidated  lung, 
and  over  lungs  of  which  the  bronchi  are  occluded. 

Suppressed  Vocal  Resonance. — There  is  absence  of  the  voice- 
sound  with   fluid    in    the    pleural    cavities,    with    intra-thoracic 


40  THE   PLEURA. 

tumors,  with  consolidation  of  the  lung,  and  with  obstructions  of 
the  bronchi. 

Bronchophony. — The  quality  is  bronchial,  the  pitch  is  high,  the 
intensity  and  the  thrill  are  variable.  It  is  heard  over  consoli- 
dated and  compressed  lung,  and  over  cavities. 

^^gophony. — This  is  a  form  of  bronchophony  characterized  by 
its  peculiar,  shrill  quality.  It  is  heard  over  lung  compressed  by 
fluid  in  the  pleural  cavity,  at  the  level  of  the  fluid. 

Pectorilogy. — Not  only  the  sound  of  the  voice  is  heard,  but 
the  articulation  of  words  can  be  distinguished.  It  is  heard  over 
large  cavities,  and  sometimes  over  consolidated  lung. 

Pleurisy. 

The  pleura  is  a  connective-tissue  membrane  composed  of 
fibrillated  connective  tissue,  with  its  basement  substance  and 
cells,  and  covered  over  its  free  surface  by  a  layer  of  endothelial 
cells.  Imbedded  in  it  are  nerves,  blood  vessels,  and  lymphatics. 
According  to  its  distribution,  we  speak  of  the  pulmonary,  costal, 
mediastinal,  and  diaphragmatic  pleura. 

The  pleura  may  become  inflamed  in  several  different  ways, 
and  we  describe  : 

Pleurisy  with  the  production  of  fibrin. 

Pleurisy  with  the  production  of  fibrin  and  serum. 

Pleurisy  with  the  production  of  fibrin,  serum,  and  pus. 

Pleurisy  with  adhesions. 

Tubercular  pleurisy. 

In  pleurisy  with  the  production  of  fibrin  alone,  or  of  both 
fibrin  and  serum,  the  morbid  changes  in  the  pleura  are  essen- 
tially the  same,  differing  only  in  the  presence  or  absence  of  the 
serum. 

The  first  change  in  the  pleura  is  simply  a  congestion  and  a 
falling  off  of  the  endothelial  cells.  Then  the  pleura  loses  its 
smooth,  shining  appearance,  and  looks  dull  and  rough,  this 
change  being  due  to  the  presence  of  small  knobs  and  threads  of 
coagulated  fibrin  on  its  surface.  At  tlie  same  time,  if  serum  is 
to  be  present,  it  begins  to  collect  in  the  pleural  cavity. 

Next  there  is  a  swelling  of,  and  a  new  growth  from,  the  con- 
nective-tissue cells  of  the  pleura,  and  an  emigration  of  white 
blood-cells  from  the  vessels.  Then  we  find  the  pleura  coated 
with  a  layer  of  fibrin  in  which  are  entangled  pus-cells  and  new 


THE   PLEURA.  41 

connective-tissue  cells.  After  this  the  new  connective-tissue 
cells  entangled  in  the  fibrin  become  more  numerous,  a  basement 
substance  and  new  blood-vessels  are  formed. 

Finally,  the  fibrin  and  the  serum  are  absorbed  and  disappear, 
and  the  pleura  is  left  thickened  and  with  connective-tissue  adhe- 
sions binding  together  its  opposed  surfaces. 

Pleurisy  with  the  Exudation  of  Fibrin.     Dry  Pleurisy. 

Lesions. — The  inflammation  begins  in  the  costal  or  pulmonary- 
pleura,  according  to  the  cause  producing  it.  It  extends  regularly 
to  the  portion  of  pleura  opposite  to  it.  Usually  only  a  circum- 
scribed portion  of  the  costal,  pulmonary,  mediastinal,  or  dia- 
phragmatic pleurals  involved,  but  sometimes  the  entire  pleura  of 
one  side  of  the  chest  is  inflamed.  The  inflamed  pleura  is  coated 
with  fibrin,  and  bands  of  fibrin  form  adhesions  between  the  op- 
posed pleural  surfaces. 

In  rare  cases  the  quantity  of  fibrin  is  so  great  as  to  compress 
the  lung. 

When  the  inflammation  has  subsided,  the  fibrin  is  absorbed, 
but  permanent  connective-tissue  thickening  and  adhesions  are 
left. 

Causes. — Exposure  to  cold  and  wet,  wounds  of  the  chest-walls, 
inflammations  of  the  lung,  peritonitis,  the  infectious  diseases,  and 
Bright's  disease  are  regular  causes  of  pleurisy.  In  some  cases 
there  seems  to  be  an  individual  predisposition  to  pleurisy,  and 
the  same  person  suffers  from  several  attacks. 

Symptoms. — The  most  constant  physical  sign  is  a  friction  sound 
— a  crepitant,  subcrepitant,  or  mucous  rale,  or  a  rubbing  sound. 
This  is  heard  over  the  inflamed  portion  of  the  pleura.  It  cannot 
be  heard  if  only  the  mediastinal  or  diaphragmatic  pleura  is  in- 
flamed. It  is  heard  only  with  inspiration,  or  with  expiration  also. 
It  is  usually  not  continuous,  but  requires  a  forced  inspiration  to 
develop  it. 

In  some  cases  there  is  also  dulness  over  the  inflamed  portion 
of  the  pleura. 

In  the  mild  cases  the  only  constitutional  symptom  is  pain  over 
the  inflamed  pleura. 

In  the  more  severe  cases  there  is  a  febrile  movement  attended 
with  prostration  and  headache,  shallow  breathing,  and  a  dry 
cough.     These  symptoms  only  last  for  a  few  days. 


42  THE   PLEURA. 

The  exceptionally  severe  cases,  with  very  large  exudations  of 
fibrin,  resemble  cases  of  lobar  pneumonia. 

The  ordinary  cases  recover  after  a  short  time,  but  the  patient 
is  left  with  permanent  thickenings  and  adhesions  of  the  pleura. 
Such  adhesions  may  give  no  further  trouble,  except  for  occasional 
pain  ;  or  they  may  form  the  starting-point  for  a  chronic  pleurisy 
with  adhesions,  followed  by  interstitial  pneumonia  and  chronic 
bronchitis. 

Treatment. — For  the  pleurisy  we  employ  wet,  or  dry,  cups,  or 
blisters  over  the  inflamed  pleura.  For  the  pain  we  use  opium. 
While  the  febrile  movement  is  present  the  patients  should  be 
kept  in  bed.  So  long  as  the  friction  sound  persists  the  patient 
must  be  kept  in  the  house  if  the  weather  is  cold,  but  in  warm 
weather  this  is  not  necessary. 

Pleurisy  with  the  Exudation   of  Fibrin  and   Serum.     Pleu- 
risy WITH  Effusion. 

The  inflammation  involves  the  greater  part  of  the  pleura  on 
one  side  of  the  chest.  Occasionally  both  sides  of  the  chest  are 
inflamed,  and  when  this  is  the  case  the  pericardium  is  apt  also  to 
be  inflamed.  The  pleural  cavity  contains  more  or  less  clear,  or 
turbid,  serum.  The  surface  of  the  pleura  is  coated  with  fibrin, 
and  bands  of  fibrin  join  together  its  opposite  surfaces.  The 
lung  is  more  or  less  compressed,  according  to  the  quantity  of 
fluid. 

After  the  inflammation  has  subsided  the  serum  and  fibrin  are 
absorbed,  and  thickenings  and  adhesions  of  connective  tissue  are 
left. 

The  compressed  lung  expands  partially  or  completely.  Ac- 
cording to  the  expansion  of  the  lung,  there  is  left  more  or  less 
retraction  of  the  affected  side  of  the  chest. 

The  Causes  are  the  same  as  those  which  produce  dry  pleurisy. 

Symptoms. — The  disease  may  run  an  acute  or  a  subacute 
course. 

I.  The  Acute  Form. — The  symptoms  begin  abruptly  with  chills, 
fever,  full  and  frequent  pulse,  pains  in  the  head  and  limbs,  vom- 
iting, and  prostration.  The  breathing  is  frequent  and  shallow, 
there  may  be  a  dry  cough,  there  is  severe  pain.  The  pain  is  re- 
ferred to  the  inflamed  pleura,  or  to  some  point  in  the  back,  or 
in  the  abdomen,  or  even  to  the  opposite  side  of  the  chest.     It 


THE   PLEURA.  43 

usually  becomes  less  severe  with  the  accumulation  of  serum  in 
the  pleural  cavity. 

After  a  few  days  the  acute  symptoms  subside.  The  inflam- 
matory products  remain  in  the  chest  for  some  time  longer.  They 
may  then  be  absorbed,  or  the  pleurisy  may  take  on  the  subacute 
form  and  last  for  a  long  time. 

2.  The  Subacute  Form. — The  symptoms  are  developed  gradu- 
ally and  slowly.  The  patients  complain  of  pain  in  the  side,  of 
dyspnoea  on  exertion,  of  a  dry  cough,  of  loss  of  appetite,  flesh, 
and  strength,  and  they  become  anaemic.  They  are,  for  a  time, 
not  confined  to  bed,  and  often  continue  at  their  work.  They 
have  a  little  fever,  the  temperature  normal  in  the  morning,  but 
running  up  to  ioo°  in  the  afternoon. 

In  some  cases,  however,  the  temperature  runs  higher  :  ioo° 
in  the  morning,  and  101°  to  103"  in  the  afternoon.  With  these 
higher  temperatures  the  patients  lose  flesh  and  strength  more 
rapidly,  and  may  sweat  at  night. 

The  Physical  Signs. — At  the  beginning  of  the  inflammation, 
when  the  pleura  is  coated  with  fibrin  and  but  little  serum  has  been 
exuded,  there  is  a  friction  sound,  which  is  a  rubbing  sound,  or  a 
crepitant  or  subcrepitant  rale.  After  the  fluid  has  been  absorbed 
there  is  again  a  friction  sound — a  subcrepitant  or  coarse  rSle,  or 
a  creaking  sound. 

When  a  considerable  quantity  of  fluid  has  accumulated  in  the 
pleural  cavity  there  are  physical  signs  due  to  the  presence  of  the 
fluid  and  the  compression  of  the  lung. 

Below  the  level  of  the  fluid  there  is  flatness  on  percussion, 
absence  of  voice,  of  breathing,  and  of  vocal  fremitus.  The  fluid 
accumulates  in  the  lower  part  of  the  pleural  cavity,  compressing 
the  lung  upward  and  against  the  vertebral  column  ;  or  in  the 
posterior  part  of  the  pleural  cavity,  compressing  the  lung  against 
the  anterior  wall  of  the  chest ;  or  it  may  be  shut  in  by  adhesions. 
The  compression  of  the  lung  is  in  proportion  to  the  quantity  of 
the  fluid. 

At  the  level  of  the  fluid  there  is  dulness  on  percussion  and 
segophony. 

Above  the  level  of  the  fluid,  over  the  compressed  lung,  the 
percussion  resonance  is  pulmonary,  or  exaggerated  and  high- 
pitched,  or  tympanitic.  The  breathing  is  pulmonary,  or  exag- 
gerated, or  broncho-vesicular,  or  bronchial. 

The  affected  side  measures  more  than  the  opposite  side  of  the 


44  THE   PLEURA. 

chest,  the  diaphragm  is  pushed  down,  the  intercostal  spaces  may- 
be forced  outward,  the  heart  may  be  displaced  toward  the  oppo- 
site side  of  the  chest. 

As  the  fluid  is  absorbed  the  voice  and  breathing  can  be  heard 
lower  and  lower  down,  the  flatness  disappears,  but  dulness  on 
percussion  remains  for  some  time  after  all  the  fluid  has  been 
absorbed. 

Exceptional  Physical  Signs. — The  vocal  fremitus  may  not  be  lost 
below  the  level  of  the  fluid.  Bronchophony  alone,  or  both 
bronchial  voice  and  breathing,  may  be  heard  below  the  level  of 
the  fluid,  especially  if  the  quantity  of  fluid  is  large  and  the  lung 
much  compressed. 

Above  the  level  of  the  fluid,  over  the  compressed  lung,  there 
may  be  cavernous  breathing  and  gurgling  rales. 

The  sacculated  effusions  give  very  irregular  physical  signs, 
varying  with  the  position  of  the  fluid. 

The  acute  cases  of  pleurisy  with  effusion  may  last  for  only  a 
few  weeks,  but  more  frequently,  whether  acute  or  subacute,  they 
last  for  weeks  or  months. 

In  a  few  cases  the  disease  terminates  fatally.  Death  is  then 
often  sudden,  and  seems  to  be  due  to  congestion  and  oedema  of 
the  other  lung,  or  to  interference  with  the  action  of  the  heart. 

In  a  moderate  number  of  cases  the  inflammation  changes  its 
character,  pus  is  added  to  the  other  inflammatory  products,  and 
the  patients  have  empyema. 

Most  of  the  patients  recover,  but  with  a  damaged  pleura,  and 
with  a  lung  which  expands  more  or  less  incompletely.  In  many 
of  them  the  only  subsequent  inconvenience  is  some  pain  on  the 
affected  side  of  the  chest  ;  but  in  others  there  is  marked  retrac- 
tion of  the  wall  of  the  chest,  chronic  pleurisy  with  adhesions,  in- 
terstitial pneumonia,  or  chronic  bronchitis.  It  may  also  happen 
that  such  a  pleurisy  will  be  succeeded  by  chronic  phthisis. 

The  displaced  heart  may  return  to  its  natural  position,  or  it 
may  remain  fastened  in  its  new  place  by  adhesions,  or  it  may  be 
drawn  over  to  the  retracted  side  of  the  chest. 

Diagnosis. — Pleurisy  with  effusion  may  be  mistaken  for  em- 
pyema, tubercular  pleurisy,  pneumonia,  phthisis,  abscess  of  the 
liver,  or  tumors  of  the  pleura.  In  many  cases  we  are  warranted 
in  drawing  off  fluid  from  the  pleural  cavity  with  a  fine  needle,  in 
order  to  establish  the  diagnosis. 

TreaUnent. — Of  the  acute  form  of  pleurisy  with  effusion,  the 


THE   PLEURA.  45 

treatment  is  that  of  an  acute  exudative  inflammation.  Wet  or  dry 
cups,  or  blisters,  over  the  affected  side  of  the  chest,  calomel,  and 
the  sulphate  of  magnesia  given  internally,  are  the  most  efficient 
remedies.  The  patients  are  to  be  kept  in  bed  and  on  a  fluid  diet. 
The  pain  and  restlessness  may  be  relieved  by  opium  combined 
with  aconite  or  veratrum  viride,  or  by  chloral  hydrate  with  one 
of  the  bromides. 

In  subacute  pleurisy  with  effusion  we  have  to  treat  the  inflam- 
mation and  the  accumulation  of  fluid  within  the  pleural  cavity. 
The  only  direct  means  of  treating  the  inflammation  is  the  use  of 
counter-irritation  over  the  affected  side  of  the  chest.  The  indi- 
rect means  are  keeping  the  patients  in  bed,  or  getting  them  out  of 
doors  in  a  suitable  climate,  according  to  the  case  ;  the  use  of  iron, 
quinine,  and  the  mineral  acids  ;  and  the  regulation  of  the  diet. 

If  the  quantity  of  fluid  in  the  pleural  cavity  is  moderate  it  can 
be  removed  by  diuretics — the  iodide  or  acetate  of  potash,  the 
diuretic  pill,  chloride  of  sodium,  cafiein,  convallaria,  digitalis. 
At  the  same  time  the  urine  is  to  be  measured  every  day,  and  the 
ingestion  of  fluids  somewhat  restricted. 

If  the  chest  is  distended  with  fluid  this  must  be  removed  by 
the  aspirator.  In  doing  this  the  strictest  cleanliness  must  be  ob- 
served, and  only  a  moderate  quantity  of  the  serum  withdrawn. 
Immediately  after  the  aspiration  the  use  of  diuretics  should  be 
begun. 

Pleurisy  with  the   Production   of   Serum,  Fibrin,  and    Pus. 

Empyema. 

Lesions. — The  inflammation  regularly  involves  the  whole  of 
the  pleura  on  one  side  of  the  chest,  less  frequently  a  circum- 
scribed portion  of  the  pleura.  The  inflammation  follows  two 
different  forms  : 

1.  The  pleura  is  coated  with  fibrin  and  pus,  and  its  cavity 
contains  purulent  serum,  but  the  pleura  itself  is  but  little 
changed.     This  form  is  most  common  in  children. 

2.  The  pleura  is  coated  with  fibrin  and  pus,  its  cavity  con- 
tains purulent  serum,  and  in  addition  the  pleura  itself  is  much 
changed.  It  is  split  up  by  great  numbers  of  new  cells,  so  that  it 
resembles  granulation  tissue. 

In  either  case  the  fluid  accumulates  in  the  lower  part  of  the 
pleural  cavity,  pushing  the  lung  upward  and  toward  the  verte- 


46  THE   PLEURA. 

bral  column  ;  or  in  the  posterior  part  of  the  pleural  cavity,  push- 
ing the  lung  forward  ;  or  it  is  sacculated  in  any  part  of  the 
pleural  cavity.  The  lung  is  usually  much  compressed.  In  old 
cases  the  pleura  becomes  much  thickened,  and  may  be  infil- 
trated v^ith  the  salts  of  lime. 

The  suppurative  process  may  extend  from  the  pulmonary 
pleura  to  the  lung,  and  the  pus  then  escape  at  intervals  from  the 
bronchi  ;  or  it  may  extend  from  the  costal  pleura  to  the  wall  of 
the  chest,  and  the  pus  escape  externally. 

In  a  few  cases  the  inflammatory  products  and  the  superficial 
layers  of  the  pleura  become  gangrenous. 

The  micro-organisms  regularly  found  are  either  streptococci 
or  pneumococci.  Thex"e  seems  to  be  no  special  difference  in  the 
clinical  symptoms  whether  the  infection  is  effected  by  one  or  the 
other  of  these  organisms. 

Symptoms. — i.  The  inflammation  may  be  primary,  after  expos- 
ure to  cold,  or  without  discoverable  cause.  The  patients  are 
suddenly  attacked  with  chills,  a  high  temperature,  marked  pros- 
tration, headache,  pains  in  the  back  and  limbs,  pain  over  the  in- 
flamed pleura,  shallow  and  painful  breathing,  sometimes  cough. 
The  symptoms  may  continue  acutely  and  the  patients  die  in  a 
short  time,  or  they  may  subside  and  the  inflammation  pass  into 
the  chronic  condition. 

2.  The  inflammation  may  be  secondary  to  a  pleurisy  with  ef- 
fusion, or  to  a  lobar  pneumonia.  A  pleurisy  with  effusion  may 
change  suddenly  or  slowly  into  an  empyema.  The  patients  lose 
flesh  and  strength  more  rapidly,  and  have  higher  temperatures. 
A  lobar  pneumonia  may  run  its  course,  convalescence  be  estab- 
lished and  continue  for  several  days,  and  then  the  temperature 
goes  up,  and  there  are  the  physical  signs  of  fluid  in  the  pleural 
cavity. 

3.  An  empyema,  after  running  its  course  for  a  shorter  or 
longer  time,  will  suddenly  change,  the  inflammatory  products 
become  gangrenous,  the  patients  pass  into  the  pyaemic  condition 
and  die  in  a  few  days. 

4.  Abscesses  in  the  wall  of  the  thorax,  in  the  liver,  in  the 
abdominal  cavity,  or  in  the  lung,  may  rupture  into  the  pleural 
cavity  and  set  up  a  purulent  inflammation. 

The  physical  signs  of  empyema  are  the  same  as  those  of 
pleurisy  with  effusion,  but  sacculation  of  the  fluid  and  irregular 
physical  signs  are  more  common. 


THE   PLEURA.  47 

The  Course  of  the  Disease. — Some  of  the  acute  cases  continue 
without  any  abatement  of  the  symptoms,  and  terminate  fatally 
within  a  short  time.  More  frequently  the  course  of  the  disease 
is  clironic.  The  patients  go  on  for  months  or  years  with  fever, 
gradual  loss  of  flesh  and  strength,  and  dyspnoea  and  cough.  In 
some  the  lung  is  perforated  and  the  pus  from  time  to  time 
coughed  up  through  the  bronchi  ;  in  some  the  wall  of  the  chest 
is  perforated  and  the  pus  imperfectly  evacuated  ;  in  some  there 
is  septic  poisoning. 

Very  rarely  does  spontaneous  recovery  take  place  ;  somewhat 
more  frequently  there  is  partial  recovery,  with  absorption  of 
some  of  the  pus  and  sacculation  of  the  remainder.  Most  of  the 
patients,  if  not  cured  by  proper  treatment,  die  exhausted  by  the 
disease,  or  with  pulmonary  phthisis,  or  with  waxy  viscera. 

The  most  difficult  cases  to  make  out  are  those  with  a  saccu- 
lated empyema.  The  patients  have  more  or  less  fever  and  go  on 
week  after  week  not  getting  well.  The  physical  signs  are  vari- 
able and  deceptive.  Rather  a  favorite  seat  of  such  an  empyema 
is  at  the  root  of  the  lung. 

The  Prognosis  is  more  favorable  in  children  than  in  adults  ;  in 
those  operated  on  early  than  in  those  operated  on  later.  It  is  un- 
favorable after  septic  poisoning  has  begun,  and  when  the  empyema 
is  caused  by  the  rupture  of  an  abscess  into  the  pleural  cavity. 

The  Diagnosis  is  between  empyema,  pleurisy  with  effusion, 
lobar  pneumonia,  broncho-pneumonia,  tubercular  pneumonia, 
and  abscess  of  the  liver. 

The  Treatment. — In  children  the  disease  can  be  cured  by  as- 
piration ;  but  if  after  two  or  three  aspirations  the  improvement  is 
not  decided,  it  is  better  to  open  the  chest. 

In  the  smaller  sacculated  collections  of  pus  in  adults  a  cure 
can  often  be  effected  by  aspiration. 

In  the  ordinary  cases  of  empyema  in  adults  the  rule  is  to  open 
the  chest  as  soon  as  the  diagnosis  is  made. 

The  regular  procedure  is  to  feel  for  the  first  rib  below  the 
angle  of  the  scapula,  to  cut  down  on  this  rib  and  remove  it  up  to 
its  cartilage,  to  put  in  a  large  drainage-tube,  sew  up  the  wound, 
and  dress  with  bichloride.  The  dressings  are  to  be  changed 
as  seldom  as  possible,  the  chest  is  not  to  be  washed  out,  and 
the  drainage-tube  should  be  removed  at  the  end  of  the  fourth 
week. 


48  THE   PLEURA. 

Chronic  Pleurisy  with  Adhesions. 

Lesions. — There  is  a  chronic  inflammation  of  the  pleura  with 
the  production  of  new  connective  tissue,  but  without  fibrin,  serum, 
or  pus.  The  inflammation  begins  at  some  part  of  the  pleura,  and 
then  extends  until  first  one  lung  and  then  both  are  completely 
covered  with  adhesions  and  fastened  to  the  wall  of  the  chest.  It 
is  not  to  be  confounded  with  the  old  adhesions  found  over  so 
many  lungs  after  death,  but  is  a  chronic  inflammatory  process 
with  the  progressive  formation  of  more  and  more  adhesions. 

Causes. — The  disease  usually  originates  in  the  adhesions  which 
have  been  left  behind  by  previous  attacks  of  dry  pleurisy,  pleurisy 
with  effusion,  or  pneumonia  ;  but  in  some  cases  no  history  of  such 
previous  acute  attacks  can  be  obtained. 

The  Symptoms  vary  with  the  extent  of  the  lesions. 

In  the  early  stages  the  only  symptoms  are  occasional  pain  over 
the  affected  part  of  the  chest,  dulness  on  percussion,  and  friction 
sounds. 

When  the  disease  is  farther  advanced,  the  pain  continues,  there 
is  a  dry  cough,  the  breathing  is  imperfect,  there  is  dyspnoea  on 
exertion,  and  the  area  of  dulness  on  percussion  and  of  the  friction 
sounds  is  larger. 

In  the  advanced  cases  the  difficulty  in  breathing  becomes  very 
marked,  the  cough  is  more  troublesome,  the  heart  is  diminished 
in  size  and  sometimes  displaced,  the  circulation  is  feeble,  the  pa- 
tients lose  flesh  and  strength.  They  usually  die  from  some  in- 
tercurrent disease,  but  occasionally  the  pleurisy  is  the  only  dis- 
coverable cause  of  death. 

Treatment. — The  patients  should  live  as  much  as  possible  in 
the  open  air.  They  may  be  benefited  by  the  use  of  cod-liver  oil, 
iron,  quinine,  or  the  mineral  acids.  They  should  practice  daily 
the  filling  and  emptying  of  the  lungs  with  air  in  as  complete  a 
manner  as  possible. 

Tubercular  Pleurisy. 

Apart  from  the  tubercular  inflammation  of  the  pleura,  which 
accompanies  general  tuberculosis  and  chronic  phthisis,  we  find 
tubercular  pleurisy  occurring  as  a  localized  tubercular  inflamma- 
tion. 

Lesions. — The  inflammation  involves  regularly  the  whole  of 


THE   PLEURA.  49 

the  pleura  on  one  side  of  the  chest,  the  costal  pleura  being  prin- 
cipally involved.  Tiie  pleura  is  of  a  bright-red  color  mottled 
with  small  white  points,  or  is  only  thickened  and  coated  with 
fibrin.  The  tissue  of  the  pleura  is  split  up  by  the  growth  of  new 
connective-tissue  cells,  and  contains  numerous  tubercle  granula. 
There  is  a  large  quantity  of  fluid  in  the  pleural  cavity,  which  is 
blood-stained,  or  purulent,  or  clear. 

Symptoms. — The  clinical  history  is  that  of  pleurisy  with  effu- 
sion, or  of  empyema,  but  the  patients  do  badly.  They  lose  flesh 
and  strength,  the  fluid  accumulates  rapidly  after  it  has  been 
drawn  off,  the  inflammation  of  the  pleura  persists,  and  the  pa- 
tients die,  either  suddenly  or  exhausted  by  the  disease,  within  a 
few  weeks  or  months. 

Treatment. — It  would  seem,  from  our  experience  of  the  treat- 
ment of  tubercular  peritonitis,  that  in  tubercular  pleurisy  it 
would  be  good  practice  to  open  the  chest. 


HVDRO-PNEUMOTHORAX. 

This  name  is  used  to  designate  the  presence  of  both  air  and 
fluid  in  the  pleural  cavity.  Such  a  condition  may  be  established 
in  several  different  ways. 

There  may  be  a  gangrenous  empyema  with  the  formation  of 
gas  in  the  pleural  cavity. 

There  may  be  an  empyema  with  an  opening  through  the  wall 
of  the  chest  or  into  the  lung. 

There  may  be  abscesses  or  gangrene  of  the  lung,  perforating 
the  pulmonary  pleura. 

There  may  be  pulmonary  phthisis,  with  softening  of  cheesy 
nodules  and  perforation  of  the  pleura. 

Symptoms. — The  only  cases  of  hydro-pneumothorax  which 
have  a  special  clinical  history  are  those  due  to  the  rupture  of  ab- 
scesses or  phthisical  nodules  in  the  lung.  There  is  first  the  his- 
tory of  the  previous  lung  disease.  Then,  suddenly,  at  the  time 
of  the  perforation,  there  is  severe  pain,  a  feeling  as  if  something 
had  given  way  within  the  chest,  urgent  dyspnoea,  a  rapid  and 
feeble  heart  action,  and  great  prostration.  The  patients  may  die 
in  collapse  within  a  few  hours  of  the  commencement  of  the  at- 
tack ;  or  the  urgent  symptoms  may  subside,  and  the  patients 
continue  to  live  for  some  time  with  the  symptoms  of  empyema 
and  phthisis. 


50  THE   PLEURA. 

Physical  Signs. — The  affected  side  of  the  chest  is  larger  than 
the  other,  and  moves  but  little  with  respiration.  The  heart  and 
the  diaphragm  are  displaced.  Vocal  fremitus  is  absent.  Percus- 
sion gives,  above  the  level  of  the  fluid,  exaggerated  pulmonary 
or  tympanitic  resonance,  or  flatness  ;  below  the  level  of  the  fluid, 
fiatiiess.  Auscultation  gives,  above  the  fluid  amphoric  breathing, 
or  absence  of  breathing  ;  below  the  level  of  the  fluid,  absence  of 
breathing.  If  the  patient  is  shaken,  we  get  the  splashing  sound 
of  the  fluid  in  the  chest  called  "  succussion."  We  may  also 
get  the  sound  resembling  drops  of  liquid  falling  into  liquid, 
called  "the  metallic  tinkle." 


THE   LUNGS. 


The  lungs  first  appear  as  two  small  protrusions  on  the  front 
of  the  oesophagus.  They  are  diverticula  of  the  hypoblast  sur- 
rounded by  mesoblast.  The  formative  process  consists  in  the 
budding  of  hypoblastic  into  mesoblastic  substance  ;  tlie  hypo- 
blast furnishing  the  lining  epithelium  and  the  mesoblast  the 
stroma.  As  the  lungs  continue  to  develop  they  look  like  glands 
with  acini  and  ducts. 

Just  before  birth  the  lungs  are  fully  formed,  but  the  air- 
spaces are  not  dilated  and  are  completely  lined  with  cuboidal 
epithelium.  After  birth  the  air-vesicles  are  dilated  and  their 
epithelium  is  flattened. 

As  the  child  becomes  older  the  air-spaces  occupy  a  larger, 
and  the  bronchi  and  the  stroma  a  smaller,  part  of  the  lung. 

In  the  adult  lung  the  stroma  is  arranged  so  as  to  divide  the 
lung  up  into  lobules,  six  or  seven-sided  blocks,  each  side  5  to  15 
mm.  long.  But  few  of  the  lobules  are  entirely  separated  from 
each  other  by  the  stroma.  The  small  bronchi  enter  the  lobules 
irregularly  and  break  up  into  terminal  bronchioles.  The  bron- 
chioles terminate  in  the  air-passages.  The  air-passages  are 
tubular  spaces  of  irregular  shape  with  air  vesicles  surrounding 
and  opening  into  them  on  every  side.  Some  air-vesicles,  how- 
ever, are  given  off  directly  from  the  bronchioles.  The  air-pas= 
sages  constitute  the  larger  part  of  the  lung,  their  walls  have  the 
same  structure  as  those  of  the  air-vesicles,  their  function  in  the 
act  of  breathing  is  the  same  as  that  of  the  vesicles. 

The  walls  of  the  air  passages  and  of  the  air-vesicles  are  com- 
posed of  a  thin  connective  tissue  membrane,  reinforced  by  elas- 
tic fibres,  with  an  abundant  system  of  capillary  vessels.  These 
walls  are  no  longer  covered,  as  at  birth,  with  a  continuous  layer 
of  epithelium.  Only  a  few  scattered  cells  of  epithelial  type  are 
left  as  indications  of  the  fcetal  epithelium. 


52  BRONCHITIS. 

The  important  portions  of  the  lung  are  : 

1.  Its  stroma,  which  holds  together  all  the  component  parts 
of  the  lung,  and,  as  the  pulmonary  pleura,  invests  its  external 
surface.  In  the  stroma  are  imbedded  blood-vessels,  lymphatics, 
and  nerves.  The  stroma  may  be  the  seat  of  exudative,  purulent, 
or  productive  inflammation. 

2.  The  bronchi,  of  which  the  walls  are  composed  of  connec- 
tive tissue,  muscle,  and  cartilage,  and  are  lined  with  a  mucous 
membrane.  The  bronchi  constitute  the  larger  part  of  the  lungs 
during  foetal  life  ;  in  the  young  child  they  continue  to  pre- 
dominate, but  in  the  adult  they  occupy  a  relatively  smaller 
space.  They  may  be  the  seat  of  acute  catarrhal,  of  chronic  ca- 
tarrhal, of  croupous  and  of  productive  inflammation. 

3.  The  air-passages  and  air-vesicles,  by  which  the  actual 
breathing  and  blood-aerating  function  of  the  lungs  is  performed. 
The  structure  of  the  walls  of  the  air-spaces  in  the  adult  is  that 
of  a  simple  connective-tissue  membrane  which  may  be  attacked 
by  exudative  or  productive  inflammation. 

4.  The  blood-vessels,  which  are  large  and  numerous  and  form 
a  network  of  capillaries  in  the  walls  of  the  air-spaces.  Any  ob- 
struction of  the  blood-vessels  interferes  with  the  breathing  func- 
tion of  the  lung,  and,  if  long  continued,  causes  changes  in  its 
structure. 

5.  The  lymphatics — vessels  throughout  the  lung  and  large 
nodes  at  the  root  of  the  lung.  Inflammation  of  the  bronchi  is 
regularly  attended  with  inflammation  of  the  lymph-nodes,  espe- 
cially in  children. 

The  stroma,  the  bronchi,  and  the  air-spaces  may  be  inflamed 
separately  or  together. 

Bronchitis. 

Causes. — Inflammation  of  the  bronchi  occurs  at  all  ages.  The 
acute  form  is.  more  common  in  children,  the  chronic  form  is 
more  common  with  emphysema,  with  heart  disease,  and  in  old. 
persons. 

Persons  living  in  cities,  those  who  are  much  confined  to  the 
house,  and  those  whose  health  has  been  enfeebled  are  especially 
Ii.able  to  the  disease. 

There  is  in  some  persons  a  very  well-marked  predisposition' 
to  inflammation  of  the  bronchi. 


BRONCHITIS.  53 

The  disease  is  especially  prevalent  in  cold  and  damp  cli- 
mates, and  during  the  cold  and  wet  months  of  the  year.  During 
some  years  it  is  much  more  prevalent  than  during  others. 

As  exciting  causes  of  bronchitis  we  recognize  exposure  to 
cold,  the  inhalation  of  irritating  gases  and  substances,  and  of 
pathogenic  bacteria. 

Measles,  whooping-cough,  influenza,  and  many  of  the  infec- 
tious diseases  are  often  complicated  by  bronchitis. 

I.    The  Acute  Catarrhal  Bronchitis  of  Adt^lts. 

Definition. — An  acute  exudative  inflammation  of  the  mucous 
membrane  of  the  bronchi. 

Lesions. — The  inflammation  involves  the  trachea,  the  larger 
bronchi  and  the  medium-sized  bronchi,  not  as  often  the  smaller 
ones.  As  a  rule  the  bronchi  of  both  lungs  are  equally  inflamed. 
The  mucous  membrane  of  the  bronchi  is  congested  and  swollen, 
at  first  it  is  dry,  afterward  coated  by  an  increased  production  of 
mucus.  There  are  also  desquamation  of  the  epithelial  cells, 
emigration  of  white  blood-cells,  diapedesis  of  red  blood-cells. 
The  lumen  of  the  bronchi  may  be  narrowed  either  by  the  con- 
gestion and  swelling  of  the  mucous  membrane  or  by  the  con- 
traction of  the  muscular  coat. 

Symptoms. — The  mild  cases  of  acute  bronchitis  are  attended 
with  cough,  accompanied  by  scanty  mucous  sputa,  by  pain  over 
the  sternum,  and  a  moderate  feeling  of  indisposition.  There 
may  be  no  physical  signs,  or  a  few  coarse  rales,  or  sibilant  and 
sonorous  breathing.  The  natural  duration  of  the  inflammation 
seems  to  be  about  a  week,  but  it  is  often  prolonged  for  a  much 
longer  time. 

In  the  more  severe  cases  there  is  a  troublesome  cough  with 
mucous  or  muco-purulent  sputa,  often  streaked  with  blood.  The 
quantity  of  expectoration  is  sometimes  very  large — more  than  a 
pint  in  twenty-four  hours. 

The  febrile  movement  precedes  and  accompanies  the  cough. 
It  is  usually  not  over  ioi°,  but  there  are  cases  with  temperatures 
of  103°  to  104°  throughout  the  disease. 

In  some  patients  bronchial  asthma  is  the  most  prominent  and 
distressing  symptom. 

The  physical  signs  are  coarse  rales  and  sibilant  and  sonorous 
breathing.     As  a  rule  these  sounds  are  equally  distributed  over 


54  BRONCHITIS. 

both  lungs,  but  occasionally  they  are  confined  to  one  side  of  the 
chest. 

Tiie  cases  vary  as  to  their  severity  and  duration.  The  pa- 
tients are  sometimes  very  ill,  but  do  not  often  die.  The  ordinary 
duration  of  the  disease  is  two  weeks,  but  it  may  last  much 
longer. 

In  some  of  the  cases  a  localized  broncho-pneumonia  is  de- 
veloped, with  dulness  and  increased  vocal  resonance  over  the 
consolidated  portion  of  the  lung. 

There  are  cases  in  which  the  bronchitis  continues  for  weeks 
and  months.  The  cough  and  muco-purulent  expectoration  con- 
tinue. There  is  an  irregular  fever  with  evening  exacerbations 
and  sweating  at  night.  The  patients  lose  flesh  and  strength,  and 
•sometimes  look  very  badly.  In  these  cases  the  sputum  should 
always  be  examined  for  tubercle  bacilli. 

Treatment. — The  milder  cases  are  not  confined  to  bed,  they 
can  eat  solid  food,  but  are  to  be  cautioned  against  undue  exposure. 
Many  of  them  recover  without  treatment,  but  in  some  remedial 
measures  are  necessary. 

The  severe  cases  have  to  be  kept  in  bed,  and  mainly  on  a  fluid 
diet. 

For  the  cases  of  bronchitis  which  need  treatment  we  employ  : 

(i)  Counter-irritation.  The  most  efficient  counter  irritation 
is  by  dry  cupping  ovsr  the  entire  chest.  More  moderate  counter- 
irritation  can  be  effected'  by  large  mustard  plasters,  irritating  lini- 
ments, and  poultices  frequently  renewed. 

(2)  Drugs.  The  specific  drug  for  acute  bronchitis  is  ipecac. 
It  seems  to  be  most  efficient  when  given  frequently  in  small  doses 
— gr.  ^-'pth  every  hour.  There  may  be  an  advantage  in  combin- 
ing the  ipecac  with  other  drugs  :  extr.  belladonna,  gr.  -^-^  ;  pulv. 
Doveri,  gr.  ■^-^\  pulv.  ipecac,  gr.  ■^^\  quinise  sulph.,  gr.  1  made 
into  a  pill  or  tablet,  taken  every  hour. 

When  there  is  a  large  expectoration  of  mucus  with  a  good  deal 
of  pus  mixed  with  it,  10-  to  20-drop  doses  of  tr.  of  nux  vomica 
are  of  much  service. 

The  bronchial  asthma  seems  most  frequently  to  be  due  to 
contraction  of  the  walls  of  the  bronchi.  If  this  is  the  case,  nitrite 
of  amyl,  nitro-glycerine,  chloral  hydrate,  or  opium-  are  indi- 
cated. 

Sometimes,  however,  the  asthma  is  associated  with  congested, 
swollen,  but  dry  bronchi,  then  is  indicated  the  use  of  muriate  of 


BRONCHITIS.  55 

pilocarpine,  gr.  y^^  ;  fl.  extr.  quebracho,  ni,  x. ;  ti.  extr.  grindelia  ro- 
busta,  1U  X.,  or  larger  doses  of  ipecac. 

In  the  protracted  cases  there  is  much  advantage  in  sending 
the  patient  to  a  dry  inland  climate. 

Of  useful  drugs  for  chronic  bronchitis  there  is  a  considerable 
number,  sometimes  one  sometimes  another  proving  the  most  ser- 
viceable :  the  mineral  acids,  the  preparations  of  turpentine,  iodide 
of  potash,  strychnia,  and  inhalations  of  creosote. 

2.  THE  ACUTE  CATARRHAL  BRONCHITIS  OF  OLD  PERSONS. 

The  lesions  are  the  same  as  in  the  bronchitis  of  adults. 

The  symptoms  are  more  severe  in  proportion  to  the  extent  of 
the  bronchitis,  and  the  disease  is  not  as  well  borne  as  it  is  in 
adults.  There  are,  from  the  first,  much  prostration  ;  an  irregular 
febrile  movement  ;  a  rapid  and  feeble  pulse  ;  difficult  and  op- 
pressed breathing  ;  cough  with  mucous  expectoration  ;  restless- 
ness, sleeplessness,  sometimes  delirium  ;  loss  of  appetite,  nausea, 
vomiting.  There  are  coarse  and  subcrepitant  rales  over  both 
lungs,  or  only  over  a  portion  of  one  lung.  In  some  cases  no 
rales^can  be  heard. 

An  acute  bronchitis  in  old  persons  is  often  alarming  and 
sometimes  fatal. 

The  treatuient  is  the  same  as  in  adults  ;  but  the  nursing  is  even 
more  important,  the  difficulty  in  feeding  the  patients  is  greater, 
and  stimulants  are  more  likely  to  be  necessary. 

3.    THE    ACUTE    CATARRHAL    BRONCHITIS    OF    CHILDREN. 

The  lesions  are  tlie  same  as  in  adults  :  congestion  and  swelling 
of  the  mucous  membrane,  after  a  time  an  increased  production 
of  mucus  with  some  subsidence  of  the  swelling.  But  as  the  lungs 
of  children  are  smaller,  as  the  bronchi  constitute  a  relatively 
larger  portion  of  the  lung,  as  the  bronchi  are  smaller  and  more 
easily  occluded,  as  such  an  occlusion  may  even  be  complete  with 
unaeration  of  portions  of  the  lung,  so  we  find  bronchitis  in  chil- 
dren to  interfere  seriously  with  the  function  of  breathing  and  to 
constitute  a  serious  disease. 

Symptoms. — An  acute  bronchitis  may  be  preceded  by  coryza, 
pharyngitis,  tonsillitis,  or  laryngitis  ;  it  may  occur  as  a  primary 
inflammation  ;  or  it  may  complicate  measles,  whooping-cough, 
or  one  of  the  infectious  diseases. 


56  BRONCHITIS. 

In  the  mild  cases  there  is  no  fever,  the  children  hardly  feel 
sick  ;  but  they  cough,  and  coarse  rales  can  be  heard  over  both 
lungs.  The  inflammation  regularly  runs  its  course  and  subsides 
within  one  or  two  weeks. 

In  the  majority  of  these  mild  cases  no  treatment  is  necessary, 
not  even  for  the  cough.  It  is  wise,  however,  to  keep  these  pa^ 
tients  in  the  house  until  the  bronchitis  has  subsided,  unless  the 
weather  is  warm  and  good. 

In  the  more  severe  cases  the  invasion  of  the  inflammation 
may  be  marked  by  general  convulsions.  There  is  a  well-marked 
febrile  movement,  the  temperature  higher  in  tlie  afternoon, 
sometimes  falling  even  to  the  normal  in  the  morning.  The  pulse 
is  rapid,  but  usually  not  feeble.  The  breathing  is  rapid,  some- 
times insufficient  ;  it  may  be  made  worse  for  a  time  by  distention 
of  the  stomach  with  food.  There  may  be  alternating  restless- 
ness and  drowsiness.  There  are  subcrepitant  and  coarse  rales 
heard  over  both  lungs,  sometimes  early,  sometimes  late  in  the 
disease. 

The  inflammation  regularly  runs  its  course  within  two  weeks, 
and  tlie  patients  recover.  But  they  are  often  alarmingly  ill  for 
several  days,  and  may  die  from  the  disease. 

In  infants  only  a  few  weeks  old,  rapid  breathing,  fever,  and 
prostration  are  the  only  symptoms,  and  the  disease  proves  fatal 
within  a  few  days. 

Treatment.  —  During"  the  first  days  of  the  inflammation  we  em- 
ploy counter-irritation  over  the  chest  by  turpentine,  croton-oil, 
or  poultices,  and  give  small  doses  of  calomel  or  sulphate  of  mag- 
nesia. Later  ipecac,  aconite,  and  opium  may  be  of  service.  But 
it  is  to  be  remembered  that  in  young  children  all  drugs  may  do 
liarm,  and  that  too  little  treatment  is  better  than  too  much. 

4.  CHRONIC  CATARRHAL  BRONCHITIS. 

Chronic  catarrhal  bronchitis  may  from  the  first  have  the 
character  of  a  chronic  inflammation  ;  it  may  follow  one  or  more 
attacks  of  acute  bronchitis  ;  it  may  complicate  gout,  emphysema, 
chronic  endocarditis,  interstitial  pneumonia,  pleuritic  adhesions, 
phthisis  ;  it  may  be  produced  by  the  inhalation  of  irritating  sub- 
stances. 

Lesions. — The  mucous  glands  produce  too  much  mucus,  they 
may  be  hypertrophied  ;  the  walls  of  the  bronchi  are  thickened 


PNEUMONIA.  57 

or  thinned  ;  the  lumen  of  the  bronchi  may  be  narrowed  or  di- 
lated. 

Sympto7ns. — In  the  mild  cases  the  patients  are  onl)'  troubled 
by  the  cough  and  expectoration,  while  their  general  health  re- 
mains good. 

In  the  severer  cases  the  cough  is  more  troublesome,  the  ex- 
pectoration more  profuse.  There  may  be  constant  or  spasmodic 
dyspnoea.  There  is  an  irregular  fever,  with  loss  of  flesh  and 
strength.  There  are  coarse  and  subcrepitant  rales,  sometimes 
sibilant  and  sonorous  breathing. 

The  disease  runs  a  protracted  course,  better  in  the  summer 
and  worse  in  the  winter.  The  patients  are  more  likely  to  die 
from  some  intercurrent  disease  than  from  the  bronchitis. 

The  Treatment  is  the  same  as  that  for  the  protracted  form  of 
acute  bronchitis. 

Pneumonia. 

The  terms  pneumonia  or  pneumonitis  are  employed  to  desig- 
nate the  inflammations  of  the  parenchyma  of  the  lung  as  distin- 
guished from  those  of  the  bronchi  and  the  pleura.  By  the  pa- 
renchyma of  the  lung  we  mean  the  air-vesicles,  the  air-passages, 
and  the  smallest  bronchi. 

There  are  a  number  of  different  forms  of  pneumonia,  distin- 
guished from  each  other  by  their  causes,  their  lesions,  and  their 
symptoms.  In  the  present  state  of  our  knowledge  we  cannot 
make  a  scientific  classification  of  these,  but  have  to  be  contented 
to  describe  the  different  varieties  of  pneumonia  under  arbitrary 
names. 

We  distinguish,  therefore  : 

Primary  lobar  pneumonia. 

Secondary  lobar  pneumonia. 

Lobar  pneumonia,  with  the  formation  of  new  connective  tis- 
sue. 

Broncho-pneumonia. 

Pneumonia  of  heart  disease. 

Interstitial  pneumonia. 

Tubercular  pneumonia. 

Syphilitic  pneumonia. 


58 


PNEUMONIA. 


PRIMARY    LOBAR    PNEUMONIA. 

Definition. — An  infectious  inflammation,  with  exudation  from 
the  blood-vessels  and  the  growth  of  pathogenic  bacteria,  which 
involves  principally  the  air-spaces  of  the  lungs. 

Synonyms.^Q>XQ\x^o\xs  pneumonia,  fibrinous  pneumonia,  lung 
fever,  pneumonitis. 

Etiology. — Lobar  pneumonia  is  a  very  widely  distributed  dis- 
ease. There  are  few  countries  in  which  it  does  not  prevail,  the 
mortality  ranging  from  i.io  to  2.30  per  cent,  for  each  1,000  in- 
habitants. 

In  the  United  States  the  disease  is  of  more  frequent  occur- 
rence in  the  South  than  in  the  North.  This,  the  following 
table,  based  on  the  eighth  and  ninth  census  reports,  conclusively 
shows : 


States  wholly  or  in  great  part  above 
the  39th  parallel. 


Maine . 

New  Hampshire 

Vermont 

Massachusetts  . . 
Rhode  Island . .. 

Connecticut 

New  York 

New  Jersey . 

Pennsylvania  . . . 

Ohio , 

Indiana 

Illinois 

Michigan 

Wisconsin 

Minnesota , 

Iowa 

Nebraska 

Oregon 

Colorado 

Average 


1,000 
Deaths. 


51.22 

62.46 
58.58 
56.29 
58.23 
55-96 
60.55 
Si-6i 
44.84 
60.27 
80.66 
77-94 
69.64 
54.55 
55-3° 
75-32 
87.30 

55.76 
50.67 


61.43 


Per 

1,000 
Inhab- 
itants. 


0.62 
0.96 

0.59 
0.98 
0.78 
0.72 
0.87 

O.S9 
0.58 
0.65 
0.88 
0.96 
0.67 
0.50 

0.39 
0.61 

0-93 
0-34 
0.48 


0.69 


States  wholly  or  in  great  part  below 
the  39th  parallel. 


1.  Delaware 

2.  Maryland 

3.  Virginia  | 

West  Virginia   j 

4.  North  Carolina 

5.  South  Carolina 

6.  Georgia , 

7.  Florida 

8.  Alabama , 

9.  Mississippi 

10.  Louisiana. '. 

11.  Texas 

12.  Arkansas 

13.  Kansas 

14.  Kentucky 

15.  Tennessee 

16.  Missouri 

17.  Nevada 

18.  California 

19.  District  of  Columbia 

Average 

Excess  over  Northern  States 


1,000 
Deaths. 


56.41 
59-59 
75-66 

71-34 
102.58 
99-54 
113-55 
123.81 
127.21 
94-15 
105-43 
183.42 
112. 13 
78.49 
84.03 
103.96 
81.30 
46.77 
60.87 


93.70 
32.27 


Per 

1,000 
Inhab- 
itants. 


0.70 
0.94 

0.80 
1.26 
1. 17 
1-39 
1-47 
1.68 
1-75 
1.58 
2.98 
1.49 
0.95 
1.04 
1.41 
1.18 
0.65 
0.98 

1.27 

0.58 


In  most  countries  in  the  temperate  zone  the  maximum  fre- 
quency of  the  disease  is  from  February  to  May. 

As  regards  New  York  City,  I  compiled  from  the  records  of 
the  Board  of  Health  the  deaths  from  pneumonia  from  March  i, 
187 1,  to  March  i,  1875,  7,873  cases.     Nearly  half  the  entire  num- 


PNEUMONIA.  59 

ber  was  in  children  under  five  years  of  age.  The  smallest  mor- 
tality was  in  persons  from  ten  to  twenty  years  old. 

The  majority  of  the  cases  occurred  in  March,  April,  and  May, 
December,  January,  and  February,  the  minority  in  June,  July, 
and  August. 

In  persons  over  five  years  old  the  curves  of  mortality  are  very 
regular,  and  the  difference  between  the  spring  and  winter  months 
and  the  rest  of  the  year  very  striking.  In  persons  over  seventy 
years  of  age  the  same  law  prevails.  In  children  under  five  years 
of  age  the  curves  are  much  less  regular. 

The  curves  of  mortality  in  general  correspond  with  those  of 
temperature,  the  greatest  mortality  with  the  lowest  temperature 
and  the  greatest  daily  range  of  temperature. 

The  disease  may  occur  in  epidemics,  confined  to  prisons, 
barracks,  asylums,  or  involving  certain  districts.  There  seems 
to  be  no  question  that  persons  living  an  out-of-door  life  in  the 
country  are  less  liable  to  the  disease  than  are  persons  living  in 
cities. 

It  has  always  been  a  matter  of  importance  to  determine 
whether  pneumonia  is  contagious,  whether  a  person  suffering 
from  the  disease  can  communicate  it  to  others.  The  disease  cer- 
tainly occurs  in  circumscribed  local  epidemics  and  from  time  to 
time  we  see  several  persons  in  one  house  successively  attacked. 
On  the  other  hand  it  is  well  known  that  physicians,  nurses,  and 
relations,  who  take  care  of  cases  of  pneumonia,  are  not  often 
attacked  by  the  disease.  For  the  present  the  question  must  be 
considered  an  unsettled  one. 

For  the  production  of  a  lobar  pneumonia  there  must  be  a 
cause  of  inflammation,  such  as  exposure  to  cold,  and  the  growth 
of  pathogenic  bacteria.  The  organism  most  frequently  found  is 
the  bacillus  described  by  Fraenkel  ;  it  is  said  to  be  found  in  over 
ninety  per  cent,  of  all  the  cases.  This  same  bacillus  is  also  found 
with  pleurisy,  pericarditis,  peritonitis,  and  cerebro-spinal  menin- 
gitis, and  is  regularly  present  in  the  saliva  and  nasal  secretions  of 
healthy  persons.  Much  less  frequently  the  bacillus  of  Fried- 
lander,  or  other  streptococci  of  suppuration  are  found. 

The  old  conception  of  pneumonia  was  that  it  was  simply  an 
inflammation  of  the  lung.  Within  a  few  years  the  opinion  that, 
on  the  contrary,  it  is  a  general  disease,  of  which  the  inflammation 
of  the  lung  is  the  characteristic  lesion,  gained  very  general  accept- 
ance.    With  our  present  knowledge  it  seems  most  probable  that 


6o  PNEUMONIA. 

pneumonia  belongs  to  the  class  of  infectious  inflammations. 
That  is,  it  is  an  inflammation  of  the  lung  accompanied  by  the 
growth  of  pathogenic  bacteria.  The  growth  of  these  bacteria  is 
attended  with  the  formation  of  poisonous  chemical  products,  and 
according  to  the  quantity  and  virulence  of  these  products  the 
symptoms  of  general  poisoning  are  more  or  less  marked. 

When  exposed  to  the  same  exciting  causes  children  under 
five  years  of  age  usually  have  broncho-pneumonia  ;  children 
between  the  ages  of  five  and  fifteen  have  either  broncho-pneu- 
monia or  lobar  pneumonia ;  adults  usually  have  lobar  pneu- 
monia. 

Morbid  Anatomy. — The  inflammation  regularly  involves  the 
whole  of  one  lobe,  or  the  whole  of  one  lung,  or  portions  of  both 
lungs. 

Juergensen,  from  a  study  of  6,666  cases,  gives  the  following 
table  to  show  the  relative  frequency  of  the  situation  of  the  lesion  : 

Per  cent. 

Right  Lung 53-7o 

"         "       upper  lobe 12.15 

"         "       middle  lobe 1.77 

"         "       lower  lobe 22.14 

"         "       whole  lung 9.35 

Left  Lung 38.23 

"         "       upper  lobe 6.96 

"         "       lower  lobe 22.73 

"         "       whole  lung 8.54 

Both  Lungs 8.07 

**         "       both  upper  lobes 1.09 

"         "       both  lower  lobes 3  34 

The  inflammation  in  acute  lobar  pneumonia  is  of  pure  exu- 
dative type,  characterized  by  congestion,  emigration  of  white 
blood-cells,  diapedesis  of  red  blood-cells,  and  exudation  of  blood- 
plasma,  and  formation  of  fibrin,  while  the  tissue  of  the  lung 
remains  unchanged.  For  clinical  purposes  it  is  important  to  have 
as  distinct  an  idea  as  possible  of  the  condition  of  the  lung  while 
it  is  the  seat  of  such  an  exudative  inflammation,  so  that  we  de- 
scribe the  condition  in  which  the  lung  is  found  while  tlie  inflam- 
mation is  going  through  its  regular  stages  of  congestion,  exuda- 
tion, and  resolution. 

During    the    first  hours   of  the  inflammation    only   irregular 


PNEUMONIA,  6l 

portions  of  the  lobe  which  is  to  be  inflamed  are  involved;  later, 
tlie  entire  lobe.  The  king  is  congested,  cedeniatous,  tough,  but 
not  consolidated.  The  air-spaces  contain  granular  matter,  fibrin, 
pus-cells,  red  blood-cells,  and  epithelial-cells.  Tlie  epithelium 
remaining  on  tlie  walls  of  the  air-spaces  is  swollen  ;  there  are 
large  numbers  of  white  blood-cells  in  the  capillaries.  The  larger 
bronchi  are  congested,  dry,  or  coated  with  mucus  ;  the  small 
bronchi  contain  the  same  inflammatory  products  as  do  the  air- 
spaces. Tlie  pulmonary  pleura,  as  a  rule,  is  not  coated  with 
fibrin.  This  is  called  the  stage  of  "  congestion."  The  stage  of 
congestion  regularly  only  lasts  a  few  hours,  but  it  may  be  pro- 
tracted for  several  days. 

When  the  exudation  of  the  inflammatory  products  has  reached 
its  full  development,  the  presence  of  these  products  within  the 
air-spaces  and  bronchi  causes  the  lung  to  be  solid,  and  at  this 
time  the  lung  is  said  to  be  in  the  condition  of  "red  hepatization." 
The  lung  is  now  consolidated,  red,  its  cut  section  looks  granular, 
the  granules  corresponding  to  the  plugs  of  inflammatory  matter 
within  the  air-spaces.  For  some  time  after  death  the  inflamma- 
tory products  remain  solid,  and  the  cut  section  of  the  lung  dry, 
but  later,  with  the  commencement  of  post-mortem  changes, 
these  products  soften  and  the  cut  section  is  covered  with  a 
grumous  fluid.  The  air-vesicles,  the  air-passages,  the  small 
bronchi,  and  sometimes  the  large  bronchi,  are  filled,  and  dis- 
tended with  fibrin,  pus-cells,  red  blood-cells,  and  epithelium. 
In  spite  of  the  pressure  on  the  walls  of  the  air-spaces,  the  blood- 
vessels in  their  walls  remain  pervious.  The  pulmonary  pleura 
is  coated  with  fibrin  and  the  interstitial  connective  tissue  of  the 
lung  is  infiltrated  with  fibrin.  The  hepatized  lobe  is  increased 
in  size,  sometimes  so  much  so  as  to  compress  the  rest  of  the 
lung.  About  one-fourth  of  the  fatal  cases  die  in  the  stage  of  red 
hepatization,  at  any  time  from  twenty-four  hours  to  eleven  days 
after  the  initial  chill. 

After  the  air-spaces  have  become  completely  filled  with  the 
exudation,  if  the  patient  continues  to  live,  there  follows  a  period 
during  which  the  exudate  becomes  first  decolorized,  and  then 
degenerated.  This  is  the  period  of  "gray  hepatization."  The 
lung  remains  solid,  its  color  changes,  first  to  a  mottled  red  and 
gray,  then  to  a  uniform  gray.  The  coloring  matter  is  discharged 
from  the  red  blood-cells  and  the  exudate  begins  to  degenerate 
and  soften.     The  lung  is  found  passing  from  red  to  gray  hepati-- 


62  PNEUMONIA. 

zation  at  any  time  between  the  second  and  the  eighteenth  day  of 
the  disease.  It  is  found  completely  gray  at  any  time  from  the 
fourth  to  the  twenty-fifth  day.  About  one-half  of  the  cases  die 
in  the  condition  of  mottled  red  and  gray  hepatization  ;  about 
one-fourth  in  the  condition  of  gray  hepatization. 

If  the  patients  recover  the  exudate  undergoes  still  further 
degeneration  and  softening,  and  is  removed  by  the  lymphatics. 
This  is  the  stage  of  "resolution."  It  should  commence  immedi- 
ately after  defervescence  and  be  completed  within  a  few  days. 
But  it  may  not  begin  until  a  number  of  days  after  defervescence, 
or  it  may  be  unusually  protracted. 

Modificatiom  of  the  Injiamniation. — The  lung,  instead  of  being 
freed  from  the  exudate  at  the  regular  time,  may  remain  in  the 
condition  of  gray  hepatization  for  weeks. 

The  quantity  of  inflammatory  products  may  be  so  great  that 
the  blood-vessels  are  compressed  and  portions  of  the  lung  be- 
come necrotic. 

There  may  be  an  excessive  production  of  pus-cells,  with  infil- 
tration of  the  walls  of  the  air-spaces  and  of  the  stroma  of  the  lung. 

The  bronchitis  may  be  developed  in  an  unusual  degree,  and 
involve  not  only  the  bronchi  of  the  inflamed  lung  but  also  those 
of  the  other  lung. 

The  pleurisy  may  be  unduly  developed  at  any  time  in  the 
course  of  the  pneumonia,  or  after  it  has  subsided. 

In  the  lobar  pneumonia  which  accompanies  epidemic  influ- 
enza there  is  often  an  intense  catarrhal  bronchitis  with  a  large 
production  of  muco-pus  ;  and  in  some  cases  an  excessive  conges- 
tion of  the  lung  with  comparatively  little  hepatization. 

The  lymphatic  vessels  in  the  pulmonary  pleura  and  in  the 
septa  between  the  lobules  may  be  filled  with  pus  cells,  and  the 
pleura  and  the  septa  infiltrated  with  fibrin  and  pus. 

It  is  often  stated  that  lobar  pneumonia  can  be  changed  into  a 
tubercular  pneumonia,  or  a  chronic  pneumonia,  but  I  believe 
that  the  cases  thus  described  are  really  examples  of  pneumonias 
which  were  of  tubercular,  or  of  productive  character  from  the 
very  outset. 

Symptoms. — Physical  signs.  During  the  stage  of  congestion 
the  lung  is  more  dense,  but  is  not  consolidated,  the  bronchi  and 
some  of  the  air-spaces  contain  inflammatory  products,  the  pleura 
is  not  yet  coated  with  fibrin.  The  percussion-note,  therefore, 
remains    unchanged,    or  its  pitch  becomes  higher,  its  duration 


PNEUMONIA,  63 

shorter,  and  its  quality  less  distinctly  pulmonary.  The  respiratory 
murmur  is  either  rude,  or  diminished  in  intensity.  The  inflam- 
matory products  in  the  small  bronchi  may  give  a  subcrepitant 
rale.  If  the  larger  bronchi  are  also  inflamed,  there  may  be  coarse 
rales  and  sibilant  and  sonorous  breathing.  As  there  is  no  fibrin 
yet  on  tlie  pleura,  there  is  no  crepitant  rale.  It  is  evident,  there- 
fore, that  during  this  stage  of  a  pneumonia  we  must  expect  that 
the  physical  signs  will  either  not  be  very  marked,  or  else  absent 
altogether. 

During  the  stages  of  red  and  gray  hepatization  the  air-spaces 
and  small  bronchi  are  filled  with  inflammatory  products  and  im- 
pervious to  air.  The  larger  bronchi  are  coated  with  mucus  or 
filled  with  fibrin.  But  although  in  all  cases  the  lung  is  consol- 
idated there  is  a  good  deal  of  difference  as  to  the  quantity  of  in- 
flammatory products,  the  size  of  the  consolidated  lobe,  the 
closeness  with  which  its  surface  is  applied  to  the  chest-wall,  and 
the  degree  of  motion  of  which  it  is  capable.  The  pulmonary 
pleura  is  coated  with  fibrin,  occasionally  there  is  serum  in  the 
pleural  cavity. 

The  percussion  sound,  therefore,  is  more  or  less  dull  or  flat, 
or  tympanitic,  or  of  cracked-pot  quality. 

Any  considerable  quantity  of  fluid  in  the  pleural  cavity  gives 
flatness. 

A  lobe  of  which  the  air-spaces  are  distended  with  exudation 
so  that  the  lobe  is  increased  in  size,  and  its  surface  pressed 
closely  against  the  wall  of  the  chest  gives  either  marked  dulness  ; 
or  flatness  ;  or  tympanitic  resonance  ;  or,  in  young  persons,  the 
cracked-pot  sound. 

The  dulness  on  percussion  is  less  marked,  or  is  even  absent 
altogether,  if  the  inflamed  lobe  is  very  much  congested  but  con- 
tains little  exudation  ;  if  the  quantity  of  exudation  is  not  suffi- 
cient to  distend  the  air-spaces  and  increase  the  size  of  the  lobe  ; 
if  the  area  of  consolidation  is  small,  or  is  situated  in  the  central 
portions  of  the  lung  ;  or  if  the  ribs  have  undergone  the  senile 
changes  which  cause  them  to  give  increased  resonance.  It  is 
especially  in  old  persons  that  these  reasons  for  the  absence  of 
dulness  on  percussion  often  exist. 

The  vocal  fremitus  is  regularly  increased  over  the  consolidated 
lung.  There  is  no  satisfactory  reason  why  this  should  not  always 
be  the  case,  but  as  exceptional  conditions  we  find  the  vocal  frem- 
itus diminished,  or  absent. 


64  PNEUMONIA. 

Bronchial  voice  and  breathing  should  be  heard  over  the  con- 
solidated lung  ;  but  we  may  get  bronchial  voice  without  bron- 
chial breathing,  or  we  may  get  neither  bronchial  voice  nor 
breathing. 

The  absence  of  bronchial  voice  seems  to  be  due  sometimes  to 
the  incomplete  consolidation,  sometimes  to  the  occlusion,  of  the 
large  bronchi.  The  absence  of  bronchial  breathing  may  be  due 
to  occlusion  of  the  large  bronchi,  or  to  the  absence  of  movements 
of  the  lung.  As  the  crepitant  rale  is  due  to  the  friction  of  the 
fibrin  on  the  surface  of  the  pleura,  the  rale  will  not  be  produced 
unless  fibrin  is  present,  and  tlie  lung  capable  of  movement.  So 
we  find  in  different  cases  a  great  difference  as  to  the  presence  or 
absence  of  the  crepitant  rale.  In  some  cases  we  only  get  it  after 
coughing,  or  with  a  forced  inspiration,  in  some  cases  it  is  only 
heard  at  the  beginning  of  red  hepatization  while  the  lung  still 
moves,  in  some  cases  it  is  heard  throughout  the  stages  of  red  and 
gray  hepatization,  in  some  cases  it  is  absent  altogetlier. 

In  the  stage  of  resolution  the  products  of  inflammation  are 
softened  and  rapidly  absorbed,  the  air  re-enters  the  small  bronchi 
and  air  spaces,  the  lung  moves  more  and  more  freely.  So  with 
the  increased  motion  of  the  lung  we  get  the  crepitant  rale  due  to 
the  friction  of  the  pleura.  With  the  softening  of  the  inflamma- 
tory products  we  get  the  subcrepitant  and  coarse  rales  in  the 
bronchi.  The  bronchial  voice  and  breathing  disappear,  if  they 
have  been  present.  Normal  vesicular  breathing  becomes  more 
and  more  distinct.  The  percussion-note  loses  its  dull,  or  flat,  or 
tympanitic,  or  cracked-pot  quality,  and  approaches  nearer  and 
nearer  to  the  normal,  but  yet  the  changes  in  the  percussion-note 
last  the  longest  of  all  the  physical  signs,  and  even  long  after 
complete  resolution  some  dulness  is  often  present. 

It  is  always  to  be  remembered  that  it  is  in  old  persons  that 
the  physical  signs  are  the  least  constant  and  the  least  well 
marked. 

Rational  Symptoms. — In  from  one-sixth  to  one-third  of  the  ca^es 
there  are  prodromic  symptoms.  Chilliness,  a  little  fever,  general 
malaise  and  feelings  of  oppression  about  the  chest  continue  for 
from  one  to  four  days.  These  symptoms  probably  correspond  to 
a  protracted  period  of  congestion. 

In  about  ninety  per  cent,  of  the  cases  there  are,  during  the 
first  twenty-four  hours,  one  or  more  decided  chills,  and  it  is  from 
the  time  of  the  chill  that  we  count  the  days  of  the  disease. 


PNEUMONIA.  65 

The  temperature  rises  at  once  and  reaches  its  maximum  by 
the  afternoon  of  the  first,  second,  or  third  day,  but  very  often  the 
highest  temperature  of  the  disease  will  be  reached  during  the 
twenty-four  hours  preceding  defervescence.  An  afternoon  tem- 
perature of  104°  F.  and  a  morning  temperature  of  102°  or  103° 
are  about  the  normal  temperatures  of  a  lobar  pneumonia.  A 
sudden  rise  of  temperature  during  the  course  of  the  disease  indi- 
cates the  extension  of  the  pneumonia,  or  the  development  of  a 
complication.  But  the  removal  of  the  patient  from  one  house  to 
another  is  regularly  followed  by  a  rise  of  temperature,  and  in 
persons  not  suffering  from  malarial  poisoning  and  not  taking 
antipyretics  there  are  quite  often  irregular  rises  and  falls  of  sev- 
eral degrees  of  temperature  which  we  cannot  account  for.  Pneu- 
monias involving  the  upper  lobes  usually  have  high  temperatures. 
The  height  of  the  temperature  is  usually  in  proportion  to  the 
severity  of  the  disease,  but  patients  may  get  worse  with  a  falling 
temperature,  or  may  die  with  temperatures  below  the  normal,  or, 
very  rarely,  have  no  rise  of  temperature  throughout  the  disease. 

Defervescence  may  take  place  at  any  time  from  the  second  to 
the  eighteenth  day  of  the  disease.  It  occurs  most  frequently  on 
the  seventh  day,  next  on  the  fifth,  eighth,  sixth,  and  ninth  days  in 
order.  The  fall  of  temperature  usually  begins  in  the  evening, 
and,  within  from  six  to  forty-eight  hours  it  reaches  the  normal, 
or  for  a  time  falls  below  it.  Occasionally  a  rapid  defervescence 
with  a  fall  of  temperature  to  97°  or  96°  is  attended  with  so  much 
prostration  and  such  a  feeble  heart-action  that  the  condition  of 
the  patient  is  alarming.  It  is  said  that  epistaxis,  haematuria,  or 
hemorrhage  from  the  bowels  may  accompany  defervescence. 

In  the  pneumonias  which  complicate  epidemic  influenza  there 
may  be  no  marked  defervescence,  but  a  gradual  fall  of  tempera- 
ture extending  over  many  days,  and  in  some  cases  the  fever  per- 
sists after  the  pneumonia  has  resolved. 

A  rise  of  temperature  after  several  days  of  partial  or  com- 
plete defervescence  usually  means  pleurisy  or  empyema,  but  it 
may  indicate  a  fresh  pneumonia,  abscess  of  the  lung,  or  gan- 
grene of  the  lung. 

The  condition  of  the  heart's  action  and  of  the  pulse  are  of 
great  importance.  In  a  favorable  case  the  pulse  ought  to  be 
about  100  to  the  minute  and  fairly  full.  A  pulse  of  over  120  is 
always  cause  for  anxiety.  The  liability  to  failure  of  the  heart's 
action,  either  gradual  or  sudden,  constitutes  one  of  the  greatest 


66  PNEUMONIA. 

dangers  of  a  pneumonia.  It  is  not  certain  what  the  cause  of  the 
heart  failure  is,  but  it  seems  probable  that  it  it  due  to  the  effects 
of  the  poison  produced  by  the  pathogenic  bacteria  of  the  dis- 
ease. In  persons  already  suffering  from  chronic  endocarditis 
failure  of  the  heart's  action  is  exceedingly  dangerous. 

The  breathing  during  the  invasion  of  the  disease  is  rapid  and 
oppressed.  As  the  disease  goes  on  the  character  of  the  breath- 
ing varies  with  the  severity  of  the  case.  Rapid,  labored,  and 
insufficient  breathing  indicates  either  inflammation  of  a  large 
part  of  the  lung,  excessive  congestion  of  the  lung,  an  intense 
general  bronchitis,  failure  of  the  heart's  action,  or  an  intense 
pleurisy  and  pericarditis. 

Cough  may  be  developed  as  one  of  the  first  symptoms,  or 
come  on  at  any  time  in  the  disease,  or  be  deferred  until  resolu- 
tion has  commenced.  In  old  persons  the  cough  is  often  slight, 
or  absent  altogether. 

The  characteristic  sputa  of  pneumonia  are  little  rounded, 
viscid  pellets  of  red,  yellow,  or  brownisli  color,  mixed  with  thin 
fluid  mucus,  the  so-called  rusty  sputa.  In  rare  cases,  with  a 
severe  invasion,  the  patients  may  cough  up  a  little  pure  blood  at 
the  beginning  of  the  disease.  In  the  bad  cases  the  sputa  are 
changed  and  the  patients  cough  up  considerable  quantities  of  a 
thin,  dark-colored  fluid.  In  some  cases  throughout  the  disease 
there  will  be  nothing  but  a  little  white  mucus  coughed  up  from 
time  to  time.  In  cases  with  an  excessive  catarrhal  bronchitis 
the  quantity  of  expectoration  may  be  very  large  and  like  that  of 
an  ordinary  bronchitis.  It  is  by  no  means  unusual,  especially  in 
old  people,  for  the  expectoration  to  be  absent  altogether. 

Pain  over  the  inflamed  lung,  referred  to  the  region  below  the 
nipple,  is  developed  within  twelve  hours  after  the  initial  chill 
in  the  majority  of  cases,  and  after  three  or  four  days  gradually 
disappears.  This  pain  is  sometimes  so  intense  as  to  be  for  a 
time  the  principal  symptom.  But  in  some  persons  there  is  no 
pain  until  resolution  commences  and  the  cough  becomes  troub- 
lesome. In  old  persons  there  is  often  not  only  an  absence  of 
pain,  but  there  are  no  abnormal  sensations  whatever  in  the  chest. 

The  expression  of  the  face  is  characteristic.  There  is  a  deep 
red  flush  at  about  the  centre  of  each  cheek,  and  the  expression 
of  the  face  is  a  curious  mixture  of  anxiety  and  apathy. 

The  skin  may  be  either  hot  and  dry,  or  bathed  in  pei-spiration 
throusfhout  the  disease. 


PNEUMONIA.  6^ 

The  tongue  is  coated  with  a  white  fur,  but  in  the  favorable 
cases  remains  moist.  A  dry  tongue  indicates  a  severe  form  of 
the  disease. 

Headache,  restlessness,  and  sleeplessness  are  troublesome 
during  the  first  days  of  the  disease  in  many  of  the  patients. 
Delirium  and  stupor  belong  to  the  severe  cases.  The  alcoholic 
patients  often  have  an  active  delirium,  or  delirium  tremens. 
Old  persons  often  become  apathetic,  or  mildly  delirious. 

The  invasion  of  the  disease  is  often  attended  with  vomiting; 
less  frequently  with  diarrhoea. 

The  urine  is  diminished  in  quantity  and  high  colored.  It 
often  contains  a  little  albumin  and  a  few  casts,  due  to  acute  de- 
generation of  the  kidney.  It  is  said  that  sodium  chloride  and 
some  of  the  other  inorganic  salts  are  diminished  in  quantity. 

Complications. — At  any  time  in  the  course  of  a  pneumonia,  or 
after  defervescence,  there  may  be  developed  pleurisy  with  effu- 
sion, or  empyema  on  the  same  side  as  the  pneumonia.  The  or- 
dinary course  is  for  the  patient  to  get  to  the  sixth  or  seventh 
day  of  his  pneumonia  and  behave  as  if  he  were  about  to  get 
well,  but  yet  without  complete  defervescence.  After  a  few  days 
the  temperature  rises  a  little  with  pleurisy  with  effusion,  a  good 
deal  with  empyema.  The  physical  signs  are  those  of  fluid  in  the 
pleural  cavity,  but  very  often  bronchial  voice  and  breathing  are 
heard  below  the  level  of  the  fluid. 

A  catarrhal  bronchitis  involving  the  larger  bronchi  of  both 
lungs  is  not  infrequent,  especially  with  the  pneumonia  of  epi- 
demic influenza.  The  patients  cough  up  large  quantities  of 
mucus,  often  mixed  with  blood.  Coarse  rales  and  sibilant  and 
sonorous  breathing  can  often  be  heard  over  both  lungs.  The 
dyspnoea  is  more  troublesome,  the  temperature  higher,  and  the 
tendency  to  heart  failure  and  venous  congestion  more  decided. 

Acute  pericarditis  is  a  serious  complication.  It  may  be  that 
there  will  be  nothing  to  call  attention  to  the  condition  of  the 
heart,  and  the  case  seems  only  to  be  a  pneumonia  of  severe  type. 
Or  there  may  be  decided  precordial  pain,  a  rapid  and  feeble 
pulse,  a  pericardial  friction  sound,  rapid  breathing,  and  cyanosis. 
It  occasionally  happens  that  the  symptoms  of  the  pericarditis 
are  more  marked  than  those  of  the  pneumonia,  so  that  it  is  even 
possible  for  the  pneumonia  to  be  overlooked. 

A  previously  existing  chronic  endocarditis  adds  much  to  the 
dangers  of  pneumonia.     The  heart's  action  is  likely  to  be  dis- 


68  PNEUMONIA. 

turbed,  and  the  condition  of  general  venous  congestion  estab- 
lished. It  must  not  be  forgotten  in  such  cases  that  a  well-marked 
mitral  or  aortic  stenosis  may  give  no  murmur  at  all. 

Acute  meningitis  is  an  infrequent  complication,  but  a  very 
fatal  one.  It  may  run  its  course  without  giving  any  distinctive 
symptoms  ;  or  the  delirium  may  be  more  active,  with  contrac- 
tions of  groups  of  muscles,  or  general  convulsions. 

Jaundice  is  seen  both  in  mild  and  in  severe  cases.  It  seems 
to  be  a  non-obstructive  jaundice  without  symptom. 

Acute  degeneration  of  tlie  kidneys,  of  mild  type,  is  of  ordinary 
occurrence.  It  seems  to  do  the  patients  no  harm  and  to  give  no 
symptoms  except  the  presence  of  albumin  and  casts  in  the  urine. 

Acute  exudative  nephritis  is  of  much  less  frequent  occur- 
rence. It  is  not  likely  to  prove  fatal  of  itself,  but  it  may  add  to 
the  dangers  of  the  pneumonia. 

Persons  already  suffering  from  chronic  nephritis  are  very  un- 
favorable subjects  for  an  attack  of  pneumonia  ;  not  many  of  them 
recover.  Quite  often  the  chronic  nephritis  is  one  which  has 
given  no  symptoms  until  the  time  of  the  pneumonia. 

The  Course  of  the  Disease. — i.  The  regular  cases.  These  cases 
may  be  mild  or  severe,  they  may  terminate  in  recovery  or  in 
death,  but  they  all  have  this  in  common,  that  the  clinical  picture 
is  that  of  an  inflammation  of  the  lung  with  comparatively  little 
evidence  of  general  poisoning.  The  patients  begin  with  the 
chills,  rapid  rise  of  temperature,  sleeplessness  and  restlessness, 
vomiting,  pain  in  the  side,  cough,  expectoration,  and  dyspnoea. 
These  symptoms  continue  either  mildly  or  severely  ;  after  the 
third  day  comes  the  liability  to  heart  failure,  and,  finally,  at  the 
regular  times  come  defervescence  or  death.  The  severity  of 
the  symptoms  is  directly  in  proportion  to  the  extent  of  lung  in- 
volved and  to  the  intensity  of  the  inflammation. 

2.  The  infectious  cases.  In  these  cases  the  symptoms  have 
no  necessary  relation  with  the  extent  of  lung  involved,  in  many 
of  them  only  a  part  of  one  lobe  is  inflamed.  The  patients  behave 
as  if  they  were  poisoned.  The  prostration  is  marked,  the  ema- 
ciation rapid.  Tiie  temperatures  are  high,  the  heart's  action  is 
rapid  and  feeble,  the  tongue  is  dr}^,  the  cerebral  symptoms  are 
marked,  and  the  disease  is  very  regularly  fatal, 

3.  The  rational  symptoms  run  their  regular  course,  but  the 
physical  signs  are  slow  in  developing,  so  that  it  may  be  as  much 
as  eight  days  before  they  are  really  well  marked. 


PNEUMONIA.  69 

4.  The  inflammation,  instead  of  remaining  confined  to  the 
lobe  in  whicli  it  began,  may  extend  to  other  portions  of  the  lungs. 
Each  extension  of  the  inflammation  is  attended  witli  an  exacer- 
bation of  the  symptoms. 

5.  There  are  rare  cases  in  which  nearly  the  whole  of  both 
lungs  becomes  at  once  inflamed,  tlie  interference  with  breathing 
is  overwiielming,  and  death  results  very  soon. 

6.  Resolution  instead  of  beginning  within  one  or  two  days 
after  defervescence,  as  it  should,  may  be  delayed  for  from  one  to 
ten  weeks.  And  yet,  even  after  these  long  periods,  the  inflam- 
matory products  may  be  absorbed. 

7.  In  some  cases,  not  necessarily  belonging  to  the  infectious 
class,  nor  alcoholic,  the  delirium  is  an  unusually  marked  symp- 
tom. In  some  of  these  patients  the  delirium  continues  for  some 
days  after  defervescence,  or  even  after  resolution  is  completed. 
In  a  few  cases  the  delirium  is  succeeded  by  permanent  insanity. 

8.  Persons  already  suffering  from  chronic  alcoholism,  if  they 
have  an  attack  of  lobar  pneumonia,  are  likely  to  have  high 
temperature,  active  delirium,  or  delirium  tremens. 

9.  The  pneumonia  of  old  persons  often  runs  an  irregular 
course.  The  extent  of  lung  inflamed  may  be  small  and  the 
physical  signs  uncertain  ;  a  little  dulness  on  percussion,  a  few 
subcrepitant  rales,  a  diminished  intensity  of  breathing,  or  even 
no  physical  signs  at  all.  The  patients  usually  have  chilliness,  or 
a  distinct  chill,  to  mark  the  invasion  of  the  disease,  and  more  or 
less  fever  while  it  is  running  its  course.  The  appetite  is  lost,  and 
there  maybe  nausea  and  vomiting.  The  pulse  is  rapid  and  often 
feeble.  Either  stupor  or  a  mild  delirium  are  often  present.  The 
prostration  is  out  of  proportion  to  the  extent  of  lung  inflamed. 
The  characteristic  cough,  expectoration,  and  pain  in  the  chest  are 
absent  altogether,  or  imperfectly  developed  ;  even  the  breathing 
may  not  be  at  all  changed.  But  the  disease  is  very  fatal  in  old 
persons,  and  some  of  them  die  quite  suddenly  after  seeming  to 
be  only  moderately  sick  for  a  few  days. 

ID.  The  pneumonia  which  accompanies  epidemic  influenza 
has,  in  New  York,  presented  certain  peculiarities.  In  many  cases 
there  was  an  intense  catarrhal  inflammation  of  the  larger  bronchi 
of  both  lungs,  with  profuse  expectoration  of  mucus  and  more  or 
less  blood.  Some  of  the  fatal  cases  showed  very  marked  conges- 
tion of  the  inflamed  lung  with  com.paratively  little  consolidation, 
and  this   corresponded   with   an   imperfect  development  of  the 


70  PNEUMONIA. 

physical  signs  of  consolidation  during  the  patient's  life.  Very 
often  there  was  no  regular  defervescence,  but  a  slow  fall  of  tem- 
perature extending  over  a  number  of  days,  and  sometimes  not 
reacliing  the  normal  until  after  resolution  was  completed.  In 
some  cases  the  whole  duration  of  the  disease  was  unusually  long, 
and  defervescence  and  resolution  did  not  take  place  until  after 
three  or  four  weeks.  Failure  of  the  heart's  action,  with  venous 
congestion  of  the  lungs  and  other  viscera  was  often  present.  The 
pneumonia  was  followed  by  empyema  in  an  unusually  large  num- 
ber of  cases. 

II.  The  course  of  the  disease  is  changed  by  the  complicating 
lesions  in  meningitis,  bronchitis,  pleurisy,  pericarditis,  endocar- 
ditis or  nephritis. 

Modes  of  Death. — The  patients  die  with  heart  failure  just 
before  defervescence  ;  from  the  extent  of  the  inflammation  ;  from 
general  poisoning;  from  one  of  the  complications  ;  from  throm- 
bosis of  the  coronary  arteries. 

Duration. — In  the  cases  which  recover,  defervescence  takes 
place  at  any  time  from  the  second  to  the  thirty-second  day,  most 
frequently  on  the  seventh  or  fifth.  Resolution  is  accomplished 
within  a  few  days  after  this,  but  may  be  delayed  up  to  ten 
weeks. 

In  the  fatal  cases  death  may  take  place  at  any  time  from  five 
hours  to  thiity  days — most  frequently  on  the  seventh,  eighth, 
and  tenth  days. 

In  persons  over  seventy  death  is  most  common  on  the  fifth, 
sixth,  and  seventh  days. 

The  mortality  from  pneumonia  is  a  considerable  one,  ranging 
in  hospitals  from  twelve  to  forty-four  per  cent.  It  seems  to  be 
the  general  impression  that  the  disease  is  more  fatal  now  than  it 
was  a  number  of  years  ago,  but  it  is  difficult  to  determine  this 
accurately.  A  study  of  this  subject  has  been  made  by  Drs. 
Townsend  and  Coolidge,  who  have  worked  up  the  records  of  the 
Massachusetts  General  Hospital  from  1822  to  1889.  They  ar- 
rived at  the  following  conclusions  : 

1.  In  the  one  thousand  cases  of  acute  lobar  pneumonia 
treated  at  the  Massachusetts  General  Hospital  from  1822  to 
1889,  there  was  a  mortality  of  twenty-five  per  cent. 

2.  The  mortality  has  gradually  increased  from  ten  per  cent, 
in  the  first  decade  to  twenty-eight  per  cent,  in  the  present 
decade. 


PNEUMONIA.  71 

3.  This  increase  is  deceptive,  for  the  following  reasons,  all  of 
which  were  shown  to  be  a  cause  of  a  large  mortality  : 

{a)  Tlie  average  age  of  the  patients  has  been  increasing  from 
the  first  to  the  last  decade. 

(d)  The  relative  number  of  complicated  and  delicate  cases 
has  increased. 

(c)  The  relative  number  of  intemperate  cases  has  increased. 

(a)  The  relative  number  of  foreigners  has  increased. 

4.  These  causes  are  sufficient  to  explain  the  entire  rise  in  the 
mortality. 

5.  Treatment,  which  was  heroic  before  1850,  transitional  be- 
tween 1850  and  i860,  and  expectant  and  sustaining  since  i860, 
has  not,  therefore,  influenced  the  mortality-rate. 

6.  Treatment  has  not  influenced  the  duration  of  the  disease 
or  of  its  convalescence. 

Treatmetit. — Lobar  pneumonia  is  a  disease  for  whicli  there  is 
no  routine  treatment  applicable  to  every  case,  on  the  contrary 
much  judgment  is  required  to  decide  what  is  the  best  way  of 
managing  each  patient. 

In  many  of  the  simple  cases  the  course  of  the  disease  is  so 
regular  and  mild  that  we  do  not  care  to  interfere  with  it  at  all. 
The  patients  are  put  to  bed,  are  given  a  fluid  diet  and  are  al- 
lowed to  go  through  the  disease  and  get  well. 

On  the  other  hand,  in  some  of  these  simple  cases  althougli 
the  disease  needs  no  treatment  there  are  symptoms  which  re- 
quire our  attention.  The  headache,  restlessness,  and  sleepless- 
ness may  be  allayed  by  the  bromides,  sulfonal,  or  opium.  Ex- 
cessive pain  in  the  chest  requires  larger  doses  of  opium,  and  in 
some  patients  the  use  of  large  poultices.  My  own  belief  con- 
cerning the  value  of  poultices  in  pneumonia  is  that  they  are  of 
no  service  except  so  far  as  they  give  comfort  to  the  patients. 
Even  in  the  simple  cases  there  is  often  the  danger  of  failure  of 
the  heart's  action,  and  this  danger,  although  it  exists  after  the 
third  day  of  the  disease,  seems  to  be  at  its  greatest  during  the 
hours  just  preceding  convalescence.  Throughout  the  disease  we 
watch  the  heart,  the  pulse,  and  the  color  of  the  skin  and  lips. 
As  soon  as  the  heart  fails  or  there  is  venous  congestion  of  the 
skin  it  is  proper  to  use  cardiac  stimulants — whiskey,  digitalis, 
strophanthus,  or  caffein.  A  very  good  combination  is  five  grains 
of  potassium  iodide,  one  minim  of  fluid  extract  of  digitalis  and 
twenty   minims    of    fluid    extract  of  convallaria  given    togetlier 


72  PNEUMONIA. 

every  three  hours.  If  the  venous  congestion  is  very  marked  a 
hypodermic  injection  of  one-fiftieth  grain  of  nitro-glycerine  will 
often  give  great  temporary  relief. 

There  are  many  cases  in  which,  although  the  course  of  the 
disease  is  regular,  the  symptoms  are  severe.  The  temperature  is 
over  104°  F.,  the  pulse  is  over  120,  the  breathing  is  insufficient, 
venous  congestion  is  evident.  So  many  of  these  patients  die  that 
it  is  not  easy  to  resign  one's  self  to  a  simply  expectant  treatment. 
The  plans  of  treatment  most  frequently  adopted  for  such  cases 
are  :  Venesection  employed  once,  or  repeated  several  times,  the 
quantity  of  blood  taken  to  be  considerable.  This  plan  is  not 
often  employed  at  the  present  time. 

Large  doses  of  calomel,  12  to  30  grains,  placed  dry  on  the 
tongue,  from  one  to  four  such  doses.  This  plan  seems  to  answer 
well  for  some  cases,  to  be  of  no  use  in  others,  and  is  attended 
with  the  risk  of  producing  salivation. 

Small  doses  of  calomel,  one-fourth  to  one  grain  given  every 
hour  up  to  six  doses.     This  seems  to  be  of  moderate  efficacy. 

Drachm  doses  of  magnesium  sulphate  given  every  hour 
up  to  eight  doses.  This  again  does  not  seem  to  be  of  much 
value. 

Either  tr.  aconite  or  veratrum  viride  in  doses  of  froni  two  to 
five  drops,  at  first  every  hour  and  later  at  longer  intervals,  have 
given  good  results  in  the  hands  of  some  physicians. 

Cold  affusions  to  the  chest,  cold  baths,  blisters,  the  antipy- 
retic drugs,  quinine,  and  carbonate  of  ammonia,  have  all  been 
much  used,  but  are  all  of  doubtful  efficacy.  In  the  cases  which 
behave  as  if  the  patients  were  poisoned,  with  high  temperature, 
cerebral  symptoms,  dry  tongue,  rapid  and  feeble  pulse,  and  rapid 
emaciation,  we  naturally  use  alcoholic  and  cardiac  stimulants 
freely,  but  in  spite  of  all  most  of  these  patients  die. 

An  excessive  catarrhal  bronchitis  may  be  benefited  by  re- 
peated dry  cupping  over  the  entire  chest,  and  by  the  administra- 
tion of  small  doses  of  ipecac  every  hour. 

For  my  own  part,  in  the  cases  of  pneumonia  which  require 
treatment,  it  has  seemed  to  me,  as  I  liave  watched  the  disease  in 
my  own  practice  and  in  that  of  other  physicians,  that : 

1.  We  have  no  plan  of  treatment  which  controls  the  inflam- 
mation of  the  lung  except  in  so  far  as  we  can  diminish  the 
venous  congestion  of  this  organ. 

2.  We  have  as  yet  no  means  by  which  we  can  prevent  or  con- 


PNEUMONIA.  73 

trol  the   poisoning  from  the  chemical   substances  produced  by 
the  growth  of  the  patliogenic  bacteria. 

3.  Reduction  of  the  temperature,  while  it  may  make  the  pa- 
tient more  comfortable,  has  no  effect  on  the  course  of  the  dis- 
ease. 

4.  The  only  thing  that  we  can  control  with  any  certainty  is 
the  circulation  of  the  blood,  and,  if  we  do  control  this  in  such  a 
way  that  the  proper  relative  quantity  of  blood  is  contained  in 
the  arteries  and  veins,  the  congestion  of  the  lungs  will  be  dimin- 
ished, the  intensity  of  the  inflammation  made  less,  and  the  dan- 
ger of  heart  failure  lessened.  This  means  that  we  must  keep 
throughout  the  disease,  no  matter  how  high  the  temperature,  a 
pulse  of  between  90  to  100  to  the  minute,  without  increased  ten- 
sion, soft,  of  good  quality,  and  of  good  strength. 

To  affect  the  circulation  in  this  way  we  have  at  our  com.mand 
a  number  of  drugs  which  increase  the  force  of  the  heart's  action 
and  which  dilate  the  arteries.  It  is  by  a  combination  of  such 
drugs  that  we  can  hope  to  regulate  the  circulation  in  the  way  in 
which  we  desire. 

The  particular  combination  which  has  seemed  to  me  to  be  the 
most  reliable  is  that  of  aconitia,  ^  milligr.  ;  digitalia,  ^  milligr.,  and 
whiskey  in  doses  of  from  one  drachm  to  one  ounce.  The  digi- 
talia and  aconitia  are  given  together  at  intervals  of  from  one  to 
three  hours,  the  whiskey  every  three  or  four  hours.  The  guide 
for  the  frequency  of  the  use  of  these  drugs  is  the  effect  on  the 
circulation.  We  try  to  keep  a  pulse  of  between  90  and  100  and 
of  good  quality ;  with  this  the  breathing  will  be  better  and  the 
disposition  to  general  venous  congestion  diminished.  The 
temperature,  however,  is  not  affected  by  this  plan  of  treatment. 

Secondary  Lobar  Pneumonia. 

Definition. — An  exudative  inflammation  involving  one  or  more 
lobes  of  the  lungs,  occurring  in  persons  already  suffering  from 
some  disease,  or  injury. 

Etiology. — Persons  who  are  confined  to  bed  by  an  infectious 
disease,  by  injuries  or  inflammations  of  the  brain  and  spinal  cord, 
by  surgical  operations,  or  by  severe  injuries,  are  liable  to  have 
venous  congestion  of  the  dependent  portions  of  the  lung,  and  to 
inhale  substances  which  can  irritate  the  lung.  In  this  way  they 
often  contract  either  a  true  broncho-pneumonia,  or  a  pneumonia 
which  somewhat  resembles  a  lobar  pneumonia. 


74  PNEUMONIA. 

Morbid  Anatomy. — The  inflammatory  process  involves  irregular 
areas  of  one  or  of  both  lungs.  We  find  these  areas  after  death  in 
the  condition  of  red  or  gray  hepatization  and  surrounded  by  con- 
gested lung,  but  no  complete  consolidation  of  an  entire  lobe. 
The  inflammation  is  of  exudative  type,  with  fibrin,  pus,  and  epi- 
thelium in  the  air-spaces  and  small  bronchi. 

Symptoms. — In  many  cases  the  pneumonia  can  hardly  be  said 
to  give  either  rational  symptoms  or  physical  signs.  We  find  the 
lesion  after  death  but  are  not  certain  of  its  existence  during 
life.  But  in  some  cases  there  are  chills,  fever,  rapid  breatliing, 
pain,  cough,  and  expectoration,  with  the  physical  signs  of  bron- 
chitis, or  of  consolidation  of  small  portions  of  the  lung. 

The  Treatment  of  such  a  pneumonia  is  unsatisfactory. 

Lobar  Pneumonia  with  the  Formation  of  Connective  Tissue. 

It  is  well  known  that  in  some  forms  of  inflammation  of  the 
lung  there  is  a  production  of  new  connective  tissue  around  the 
bronchi  and  blood-vessels,  in  the  septa  between  the  lobules,  and 
in  the  walls  of  the  air-spaces.  It  is  not  as  well  known  that  in 
these  same  forms  of  pneumonia  there  may  be  also  a  production 
of  new  connective  tissue  in  the  cavities  of  the  air-spaces  and  of 
the  small  bronchi.  This  new  tissue  either  grows  directly  from 
the  walls  of  the  air-spaces,  or  is  formed  out  of  plugs  of  coagu- 
lated matter  and  of  cells  which  are  formed  within  their  cavities. 

Such  a  productive  pneumonia  has  been  recognized  under  a 
variety  of  names  :  gray  induration,  fibroid  induration,  cirrhosis, 
interstitial  pneumonia,  chronic  pneumonia,  desquamative  pneu- 
monia, parenchymatous  pneumonia,  etc.  If  we  look  over  all  the 
different  lungs  in  which  such  a  productive  pneumonia  has  been 
developed,  we  find  that  they  can  be  classified  as  follows  : 

1.  A  productive  pneumonia  associated  with  the  growth  of 
tubercle  bacilli. 

2.  A  productive  pneumonia  associated  with  the  growth  of 
actinomyces. 

3.  A  productive  pneumonia  due  to  the  inhalation  of  particles 
of  coal  or  of  stone. 

4.  A  productive  pneumonia  caused  by  constitutional  syphilis. 

5.  A  productive  pneumonia  secondary  to  changes  in  the 
pleura. 

6.  Broncho-pneumonia, 

7.  A  special  form  of  lobar  pneumonia. 


PNEUMONIA.  75 

It  is  concerning  this  last  variety  of  productive  pneumonia 
that  our  information  is  the  least  exact,  and  it  is  to  this  variety 
that  I  wish  especially  to  call  attention.  The  ordinary  belief  has 
been  that  it  is  possible  for  a  regular  exudative  lobar  pneumonia, 
instead  of  resolving,  to  be  succeeded  by  a  chronic  productive  in- 
flammation ;  I  believe,  on  the  contrary,  that  a  regular  exudative 
lobar  pneumonia  terminates  only  in  resolution  or  in  death,  and 
that  lobar  pneumonia  with  the  production  of  new  connective  tis- 
sue is  from  the  first  a  special  form  of  inflammation  of  the  lung. 
My  reason  for  this  belief  is  that  I  have  seen  a  number  of  lungs 
which  seem  to  show  the  different  stages  of  the  inflammatory 
process. 

The  literature  on  the  subject  is  not  very  abundant.  Charcot^ 
describes  this  condition  as  following  one  or  more  attacks  of  or- 
dinary lobar  pneumonia.  Coupland  *  gives  a  very  good  descrip- 
tion with  drawings,  and  believes  that  the  new  tissue  is  formed 
from  the  intra-alveolar  exudation  of  ordinary  lobar  pneumonia. 
Kidd^  describes  two  cases  with  a  subacute  history,  which  he 
regards  as  cases  of  lobar  pneumonia  terminating  in  induration. 
Buhl^  considers  the  disease  to  be  a  primary  one,  which  runs  a 
subacute  course  and  has  nothing  to  do  with  ordinary  pneumonia. 
Heitler  *  gives  an  account  of  the  disease  as  observed  in  five  cases. 
The  development  of  the  disease,  he  says,  is  more  or  less  acute, 
with  fever,  dyspnoea,  cough,  prostration,  sometimes  rigors ;  the 
constitutional  depression  is  much  less  marked  than  in  acute 
pneumonia.  The  fever  is  irregular,  and  not  over  102°.  The 
sputum  is  mucous,  muco-purulent,  or  fetid.  In  two  of  the  cases 
there  was  retraction  of  the  wall  of  the  thorax.  The  consolidation 
involved  in  three  cases  the  right  upper  lobe,  in  one  case  the  whole 
right  lung,  in  one  case  the  lower  right  lobe.  The  hepatization 
was  smooth,  with  necrotic  and  cheesy  areas  and  cavities.  The 
course  of  the  disease  was  subacute,  but  with  an  acute  invasion, 
lasting  from  fifty  days  to  nine  months  and  nineteen  days.  Wag- 
ner °  has  described  six  cases  apparently  belonging  to  this  group, 
running  a  subacute  course  with  retraction  of  the  wall  of  the 
chest,  but  terminating  in  recovery. 

•  Rev.  Mens,  de  Med.  et  Chir.,  1878,  p.  776. 

2  Transactions  London  Pathological  Society,  vol.  xxx.,  p.  224. 

3  Lancet,  April  5,  1890. 

4  Buhl :  Briefe,  p.  47. 

^  Wiener  med.  Wochenschrift,  1884  and  1886. 
«  Deutsch.  Arch.  f.  klin.  Med.,  vol.  xxxiii. 


76  PNEUMONIA. 

I  have  seen  twelve  cases  which  seem  to  belong  to  this  group, 
and  to  demonstrate  that  there  is  a  form  of  lobar  pneumonia 
which  is,  from  the  outset,  anatomically  distinct  from  the  ordinary- 
form.  It  is  from  the  first  an  exudative  inflammation  with  the 
production  of  new  tissue,  not  a  simple  exudative  inflammation. 
Such  an  inflammation  naturally  lasts  longer,  and  is  more  likely 
to  become  chronic  than  is  the  case  with  a  simple  exudative  in- 
flammation. I  can  see  no  reason  to  believe  that  in  ordinary 
lobar  pneumonia  the  pus  and  fibrin  are  ever  replaced  by  connec- 
tive tissue. 

The  development  of  the  lesion  seems  to  be  as  follows  : 

1.  Congestion  of  the  lung  ;  exudation  of  serum,  fibrin,  and 
pus  into  some  of  the  air-spaces  ;  the  formation  in  other  air-spaces 
of  irregular  plugs  with  prolongations  from  one  space  into  others, 
the  plugs  composed  of  a  nearly  homogeneous  or  finely  fibril- 
lated  material,  none  of  them  large  enough  to  fill  or  distend  the 
air-spaces  ;  a  swelling  and  thickening  of  the  walls  of  the  air- 
spaces, with  a  very  considerable  increase. in  the  number  of  epi- 
thelial cells  which  cover  them  ;  more  or  less  general  catarrhal 
bronchitis  ;  fibrin  on  the  pulmonary  pleura. 

2.  New  cells,  of  the  type  of  connective-tissue  cells,  are  formed 
in  the  plugs  ;  the  walls  of  the  air-spaces  are  more  swollen,  and 
may  be  infiltrated  with  small  round  cells  ;  new  blood-vessels  are 
formed  in  the  plugs,  which  can  be  artificially  injected  from  the 
pulmonary  vessels.  The  gross  appearance  of  the  lung  at  this 
time  is  usually  characteristic.  One  or  more  lobes  are  consoli- 
dated, they  are  not  large,  as  in  ordinary  pneumonia,  their  color 
is  red  or  gray,  the  cut  surface  is  smooth,  not  granular. 

3.  The  growth  of  new  connective  tissue  within  the  air-spaces, 
in  their  walls,  and  along  the  arteries  and  bronchi,  is  so  extensive 
that  many  of  the  air-spaces  are  obliterated.  The  surface  of  the 
lung  is  now  covered  with  connective-tissue  adhesions  ;  the  bron- 
chi contain  muco-pus  ;  the  lung  is  red,  mottled  wnth  white,  or 
gray,  or  black  ;  it  is  dense  and  hard  ;  portions  of  it  may  be  ne- 
crotic, or  cheesy,  or  broken  down  into  cavities. 

Four  of  my  cases  illustrate  the  first  period  of  the  development 
of  the  lesion  : 

Case  I. — The  duration  of  the  disease  was  ten  days.  The  en- 
tire left  lung  was  consolidated,  small,  smooth,  of  gray  color,  with 
fibrin  coating  the  pulmonary  pleura.     The  right  lower  lobe  was 


PNEUMONIA,  77 

partly  hepatized  and  red.  The  walls  of  the  air-spaces  were 
thickened  and  coated  with  epithelial  cells.  There  was  a  growth 
of  new  connective  tissue  around  the  blood-vessels  and  bronchi. 
The  air-spaces  contained  small,  anastomosing  plugs  of  a  nearly 
homogeneous  matter. 

Case  II. — The  duration  of  the  disease  was  seventeen  days 
The  left  lower  lobe  was  consolidated,  small,  red,  and  smooth,  its 
surface  covered  with  old  adhesions.  The  walls  of  the  air-spaces 
were  thickened,  their  cavities  contained  the  plugs  already  de- 
scribed. 

Case  III. — The  duration  of  the  disease  was  fourteen  da3's. 
There  was  a  general  bronchitis.  The  right  upper  lobe  was  con- 
solidated, of  reddish-gray  color,  its  pleura  coated  with  fibrin. 
The  walls  of  the  small  bronchi  were  thickened  and  infiltrated 
with  cells.  The  walls  of  the  air-spaces  were  thickened  and 
coated  with  epithelium.  Some  of  the  air  spaces  contained  pus 
and  fibrin,  others  the  plugs  already  mentioned. 

Case  IV. — The  duration  of  the  disease  was  seven  days.  The 
left  lower  lobe  presented  the  regular  picture  of  the  red  hepati- 
zation of  ordinary  pneumonia.  The  left  upper  lobe  was  consoli- 
dated, small,  smooth,  and  red.  The  walls  of  the  air  spaces  were 
thickened  and  coated  with  epithelium,  their  cavities  contained 
pus  and  fibrin,  or  the  plugs. 

Six  of  my  cases  illustrate  the  second  period  of  the  develop- 
ment of  the  lesion  : 

Case  V. — Duration  nineteen  days.  The  right  upper  lobe  was 
consolidated,  smooth,  and  red.  There  was  a  growth  of  new 
connective  tissue  around  the  arteries,  in  the  septa,  and  in  the 
walls  of  the  air-spaces.  Some  of  the  air-spaces  contained  epithe- 
lium, others  plugs  of  the  same  shape  and  appearance  as  seen  in 
tlie  preceding  group  of  cases,  but  there  were,  in  addition,  con- 
nective-tissue cells  imbedded  in  the  basement  substance  compos- 
ing the  plugs. 

Case  VI. — Duration  sixteen  days.  The  right  middle  and 
lower  and  left  lower  lobes  were  consolidated,  small,  and  smooth. 
The  walls  of  the  air  spaces  were  thickened.  Some  of  their  cav- 
ities contained  fibrin  and  pus,  others  plugs  of  connective  tissue 
containing  blood  vessels. 

Case  VII. — Duration  twenty- three  days.     The  left  lower  lobe 


78  PNEUMONIA. 

was  consolidated,  small,  and  gray.  The  walls  of  the  air  spaces 
were  thickened  ;  they  contained  plugs  of  connective  tissue. 

Case  VIII. — Duration  twenty-eight  days.  The  left  upper 
lobe  was  consolidated,  small,  smooth,  and  black.  The  walls  of 
the  air-spaced  were  thickened  ;  they  were  covered  with  epithe- 
lium, and  contained  plugs  of  connective  tissue. 

Case  IX. — Duration  six  days.  General  bronchitis.  The  left 
upper  lobe  was  consolidated,  large,  and  red.  The  walls  of  the 
air-spaces  were  thickened  Some  contained  pus  and  fibrin, 
others  plugs  of  connective  tissue. 

Case  X. — Duration  thirteen  days.  The  left  lower  lobe  was 
in  the  condition  of  ordinary  red  iiepatization.  The  right  upper 
lobe  looked  like  the  resolution  of  an  ordinary  pneumonia,  and 
some  of  the  airspaces  contained  degenerated  exudation,  but  in 
others  there  were  plugs  of  connective  tissue. 

Two  cases  illustrate  the  third  period  of  development  of  the 
lesion  : 

Case  XL — Duration  fifty  two  days.  The  left  lung  was  cov- 
ered with  old  adhesions,  consolidated,  hard,  smooth,  mottled  red 
and  white,  small.  The  growth  of  new  connective  tissue  in  the 
walls  of  the  aii'-spaces  and  in  their  cavities  had  nearly  obliterated 
the  natural  structure  of  the  lung. 

Case  XII. — Duration  fifty-one  days.  The  pleura  was  thick- 
ened and  coated  with  fibrin.  The  left  pleural  cavity  was  half 
full  of  serum.  The  left  upper  lobe  was  consolidated,  and  of  a 
pinkish-white  color.  It  was  almost  entirely  changed  into  con- 
nective tissue. 

Etiology. — In  three  of  the  case«  there  was  a  distinct  history 
of  prolonged  exposure  to  cold  and  wet.  In  one  case  the  symp- 
toms followed  immediately  after  the  patient  having  fallen  into 
an  excavation.  In  one  case,  for  twenty  days  before  the  initial 
chill  the  patient  was  miserable,  and  had  a  troublesome  cough. 
In  one  case,  for  twenty-one  days  before  the  initial  chill,  the  pa- 
tient suffered  from  headache,  loss  of  appetite,  and  prostration. 
In  one  case,  under  observation  throughout,  there  was  an  attack 
of  lobar  pneumonia  terminating  in  resolution  after  eleven  days  ; 
the  patient  was  discharged  from  the  hospital  well,  and  after  an 
interval  of  eighteen  days  came  the  beginning  of  the  fatal  attack 


PNEUMONIA.  79 

in  the  other  lobe  of  the  same  lung.  In  one  case  the  patient 
stated  that  he  had  an  attack  of  pneumonia  five  years  before,  and 
that  for  one  year  he  had  been  troubled  with  cough  and  muco- 
purulent expectoration. 

Sympto7ns. — In  ten  of  the  cases  the  invasion  of  the  disease 
was  marked  by  chills  and  a  rapid  rise  of  temperature.  There 
was  cough  in  all  the  cases,  the  sputa  rusty  in  five  cases,  muco- 
purulent in  two  cases,  bloody  in  one  case.  The  temperature  was 
rarely  over  104°  F.,  and  in  some  of  the  cases  not  over  100°  F. 
In  seven  of  the  cases  delirium  is  noted  as  a  prominent  symptom. 
One  case  was  supposed  to  be  acute  phthisis,  one  acute  menin- 
gitis, and  one  acute  general  tuberculosis.  Three  of  the  patients 
passed  fairly  into  the  typhoid  condition.  The  physical  signs  of 
the  consolidation  of  the  lung  were  well  marked,  except  in  one 
case.  The  duration  of  the  disease  was  for  6,  7,  10,  13,  14,  16,  17, 
19,  23,  28,  51,  and  52  days  ;  in  most  of  the  cases  longer  than  that 
of  an  ordinary  lobar  pneumonia. 

There  seems  to  be,  therefore,  a  form  of  lobar  pneumonia 
which  is  anatomically  different  from  the  regular  form.  Its  phys- 
ical signs  are,  of  course,  the  same,  but  its  clinical  symptoms  are 
somewhat  different.  Although  the  patients  have  the  same  chill, 
fever,  cough,  expectoration,  and  pain  as  in  the  regular  cases,  yet 
there  is  something  about  the  course  of  the  disease  which  makes 
its  diagnosis  possible,  even  during  its  early  days.  The  tempera- 
tures do  not  run  high,  but  the  tendency  to  cerebral  symptoms 
and  the  typhoid  state  is  very  marked,  and  most  of  the  cases  run 
a  protracted  and  subacute  course.  Concerning  the. prognosis,  it 
is  not  possible  to  speak  certainly,  but  there  seems  no  reason  why 
recovery  should  not  be  possible. 

Broncho-pneumonia. 

Definition. — An  infectious  inflammation  with  exudation  from 
the  blood-vessels,  a  formation  of  new  connective  tissue  and  the 
growth  of  pathogenic  bacteria,  which  involves  principally  the 
walls  of  the  bronchi  and  the  air-spaces  which  surround  the  in- 
flamed bronchi. 

Synonyins. — Capillary  bronchitis,  lobular  pneumonia,  catarrhal 
pneumonia. 

There  seems  to  be  no  form  of  pneumonia  which  does  not 
have  associated  with  it  more  or  less  bronchitis,  so  that  every 
pneumonia  is   in  one   sense  a  broncho-pneumonia.     But  it  has 


8o  PNEUMONIA. 

long  been  recognized  that  there  is  one  form  of  inflammation  of 
the  lung  which  is  different  from  others  and  in  which  the  share  of 
the  bronchi  is  especially  important.  For  several  reasons,  how- 
ever, the  popular  notions  concerning  the  disease  have  become 
somewhat  confused.  It  was  seen  that  in  some  cases,  while  there 
was  a  bronchitis  extending  down  to  the  small  bronchi,  there  was 
no  consolidation  of  the  lung,  and  so  these  were  called  cases  of 
capillary  bronchitis.  It  was  seen  that  there  were  cases  of  gen- 
eral bronchitis  with  consolidation  of  circumscribed  portions  of 
the  lung,  and  it  was  inferred  that  the  inflammation  extended 
from  the  bronchi  to  the  air-spaces  which  empty  into  them,  so 
these  were  called  cases  of  lobular  pneumonia.  This,  however, 
was  an  error  in  observation.  Areas  of  atelectasis  do  correspond 
to  bronchi,  but  the  areas  of  consolidation  do  not  so  correspond. 
It  was  seen  that  in  some  cases  the  symptoms  and  lesions  could 
not  be  distinguished  from  those  of  phthisis,  and  it  was  not  under- 
stood that  the  only  real  difference  between  the  two  was  the 
presence  or  absence  of  the  tubercle  bacilli.  A  number  of  curi- 
ous ideas  were  connected  with  the  term  "catarrhal  inflammation" 
and  it  was  not  realized  that  a  catarrhal  inflammation  is  nothing 
but  an  exudative  inflammation  occurring  in  a  mucous  membrane. 

It  is  to  be  regretted  that  the  erroneous  idea  still  exists  that  a 
broncho-pneumonia  is  simply  an  inflammation  of  tlie  bronchi 
w^hich  extends  to  the  air-spaces  opening  into  these  bronchi. 

Etiology. — Broncho-pneumonia  is  the  ordinary  pneumonia  of 
children,  it  is  frequently  seen  in  young  persons,  and  occasion- 
ally in  adults  and  old  persons. 

It  occurs  as  a  primary  inflammation,  is  often  secondary  to 
measles,  whooping-cough,  and  diphtheria,  less  frequently  to  the 
other  infectious  diseases.  Persons  confined  to  bed  by  injury  or 
disease,  and  persons  with  emphysema  are  liable  to  subacute 
forms  of  broncho-pneumonia. 

The  disease  is  most  frequent  during  the  cold  and  wet  months 
of  the  year  ;  in  some  cases  there  is  a  history  of  exposure  to  cold, 
in  others  no  exciting  cause  is  discoverable. 

Children  crowded  together  in  asylums  are  especially  liable  to 
the  disease. 

The  same  patient  not  infrequently  suffers  from  several  attacks 
of  broncho-pneumonia. 

The  pathogenic  bacteria  are  either  the  pneumococci  of  lobar 
pneumonia,  or  the  bacteria  of  suppuration. 


PNEUMONIA.  8 1 

Morbid  Anatomy. — In  persons  who  die  from  broncho  pneumonia 
the  lungs  after  death  present  considerable  variety  in  their  gross 
appearance.  The  mucous  membrane  of  the  trachea  and  large 
bronchi  may  appear  to  be  normal,  or  is  congested  and  coated 
with  mucus,  or  the  small  bronchi  may  contain  pus.  The  walls 
of  the  small  bronchi  are  thickened  so  that  a  section  of  the  lung 
looks  studded  with  little  nodules.  In  some  cases  most  of  the 
small  bronchi  of  both  lungs  have  their  walls  thickened  in  this 
way,  more  frequently  it  is  only  the  bronchi  of  one  lung  or  of  one 
lobe.  Around  the  bronchi  whose  walls  are  thickened  are  zones 
of  consolidated  lung  from  the  size  of  a  pin-head  to  that  of  a 
pea.  Scattered  through  one  or  both  lungs  are  irregular  areas 
of  consolidation,  having  no  definite  relation  with  the  bronchi. 
They  may  be  so  large  and  numerous  that  an  entire  lobe  or  an 
entire  lung  is  completely  consolidated.  The  pulmonary  pleura 
may  be  coated  with  fibrin.  In  the  lungs  of  very  young  chil- 
dren there  may  be  consolidated  shrunken  portions  due  to  col- 
lapse of  the  air-vesicles,  the  so-called  areas  of  atelectasis.  The 
same  condition  is  found  with  bronchitis,  and  in  children  who 
die  so  soon  after  birth  that  the  whole  of  the  lungs  have  not 
become  aerated.  The  bronchial  glands  are  usually  swollen  and 
inflamed. 

The  smaller  bronchi  may  be  dilated.  In  the  portions  of  lung 
which  are  not  consolidated  the  air-spaces  may  be  somewhat  di- 
lated. Occasionally  some  of  the  air-spaces  are  ruptured,  and  the 
septa  between  the  lobules  are  infiltrated  with  air. 

In  order  to  understand  the  true  anatomical  characters  of 
broncho-pneumonia,  it  is  necessary  to  determine  which  of  these 
different  changes  is  essential  and  constant  and  which  are  acces- 
sory and  inconstant. 

The  essential  and  constant  lesion  is  a  productive  inflammation 
of  the  walls  (not  the  mucous  membrane)  of  the  bronchi,  and  of 
the  air-spaces  immediately  surrounding  the  inflamed  bronchi. 
The  walls  of  the  bronchi  are  thickened  and  infiltrated  by  a  growth 
of  new  cells ;  the  walls  of  the  air-spaces  are  thickened,  their  cavi- 
ties are  filled  with  new  connective  tissue,  or  with  fibrin,  pus,  and 
epithelium.  The  inflammation  is  from  the  first  not  exudative, 
but  productive,  that  is,  with  the  formation  of  new  tissue.  It  in- 
volves the  medium-sized  and  smaller  bronchi  of  both  lungs,  but 
is  not  everywhere  equally  severe  ;  in  some  parts  of  the  lungs  the 
lesions  are  much  more  marked  than  in  others. 


82  PNEUMONIA. 

The  accessory  lesions,  some  of  which  are  present  in  one  case 
and  some  in  others,  are  : 

1.  A  catarrhal  inflammation  of  the  mucous  membrane  of  the 
bronchi. 

2.  An  exudative  inflammation  of  the  air-spaces,  which  fills 
their  cavities  with  fibrin,  pus,  and  epithelium,  and  produces  con- 
solidation of  larger  or  smaller  portions  of  the  lungs.  In  young 
children  the  epithelial  cells  which  line  the  air-spaces  are  much 
more  numerous  than  they  are  in  adults,  so  when  children's  lungs 
are  inflamed  the  epithelial  cells  form  a  larger  part  of  the  inflam- 
matory product  than  they  do  in  the  lungs  of  adults. 

3.  An  exudative  inflammation  of  the  pleura,  which  coats  it 
with  fibrin. 

4.  Dilatation  of  the  bronchi,  of  which  the  walls  are  the  seat 
of  productive  inflammation. 

5.  Areas  of  atelectasis. 

6.  Simple,  or  tubercular  inflammation  of  the  bronchial 
glands. 

As  the  inflammation  of  the  walls  of  the  bronchi  and  of  the 
air-spaces  surrounding  them  is  from  the  first  a  productive  inflam- 
mation it  follows  the  law  which  governs  that  form  of  inflamma- 
tion. It  is  apt  to  last  for  a  longer  time  than  does  an  exudative 
inflammation,  and  it  is  liable  to  change  into  a  chronic  productive 
inflammation. 

It  is  not  uncommon,  therefore,  for  a  broncho-pneumonia  to 
continue  for  several  weeks,  or  to  be  followed  by  permanent 
changes  in  the  lungs. 

If  the  broncho-pneumonia  becomes  chronic  the  inflammation 
of  the  walls  of  the  bronchi  and  of  the  air  spaces  w^hich  surround 
them  continues,  we  then  find  that  the  bronchi  are  dilated,  their 
walls  are  thickened,  tliey  are  surrounded  by  zones  of  connective 
tissue  ;  or  part  of  a  lobe,  or  an  entire  lobe,  is  entirely  changed 
into  connective  tissue.  The  pulmonary  pleura  may  also  be  very 
much  thickened. 

Symptoms. — In  very  young  infants  the  only  symptoms  are  : 
Fever,  prostration,  and  rapid  breathing.  There  is  no  cough  ; 
there  are  no  physical  signs.  The  disease  is  almost  certainly  fatal 
within  a  very  few  days. 

In  older  children  the  broncho-pneumonia  may  be  preceded 
by  the  symptoms  of  measles,  of  whooping-cough,  of  coryza,  of 
pharyngitis,  or  of  a  catarrhal  bronchitis  of  the  larger  tubes  ;  or 


PNEUMONIA.  83 

it  may  begin  without  having  been  preceded  by  any  other  morbid 
conditions. 

Tliere  is  a  good  deal  of  difference  in  the  different  cases  as  to 
the  severity  of  the  invasion.  The  more  severe  cases  are  ushered 
in  by  one  or  more  general  convulsions  ;  or  by  a  rapid  rise  of 
temperature,  vomiting,  oppressed  breathing,  and  delirium.  The 
milder  cases  begin  with  lower  temperatures,  moderate  prostra- 
tion, and  increased  frequency  of  breathing. 

After  the  disease  is  established  the  patients  continue  to  have 
a  febrile  movement.  Tlie  temperature  in  most  cases  is  irregular, 
but  on  many  days  up  to  105°  F.  Very  often  the  temperature  is 
of  distinctly  remittent  type,  a  morning  temperature  of  99°  to  100° 
F.,  and  an  evening  temperature  of  104°  to  105°  F.  It  is  to  be 
noticed,  however,  that  in  children  both  bronchitis  and  lobar 
pneumonia  are  also  often  accompanied  by  fever  of  a  remittent 
type.  It  may  very  well  be  that  this  disposition  to  remission  be- 
longs rather  to  the  age  of  the  patient  than  to  the  character  of 
the  disease.  The  height  of  the  temperature  varies  from  day  to 
day,  sometimes  with  the  progress  or  extension  of  the  inflamma- 
tion, sometimes  without  discoverable  cause.  In  the  cases  which 
recover  it  requires  several  days  for  the  temperature  to  fall  to  the 
normal.  The  height  of  the  temperature  is  regularly  in  propor- 
tion to  the  severity  of  the  broncho- pneumonia  ;  with  tempera- 
tures of  over  105°  F.  the  mortality  of  the  disease  is  considerable. 
There  are,  however,  patients  in  whom  the  temperature  runs  be- 
tween 99°  and  100°  F.  who  do  very  badly. 

In  children  the  pulse  is  more  rapid  than  it  is  in  adults,  and  is 
also  more  easily  rendered  rapid  by  disease.  So  in  broncho- 
pneumopias  pulses  of  from  140  to  170  to  the  minute  are  not  un- 
common, and  in  bad  cases  the  pulse  can  hardly  be  counted. 

An  increase  in  the  frequency  of  the  breathing  is  almost  con- 
stantly present,  as  much  as  40  to  the  minute  even  in  mild  cases, 
up  to  60,  70,  or  80  in  the  bad  cases.  It  is  of  importance  to  no- 
tice not  only  the  frequency  of  the  breathing,  but  also  how  much 
air  enters  into  the  lungs.  The  breathing  may  be  made  worse  for 
a  time  by  distention  of  the  stomach. 

Sleeplessness,  restlessness,  and  delirium  are  often  present, 
and  sometimes  very  troublesome.  They  seem  to  depend  partly 
on  the  fever,  partly  on  the  interference  with  breathing,  partly  on 
the  temperament  of  the  child. 

The  face  is  flushed,  the  tongue  is  coated  and  sometimes  dry. 


84  PNEUMONIA. 

there  may  be  vomiting  or  diarrhoea  ;  sometimes  there  is  pain  over 
the  chest. 

Cough  is  often  present,  dependent  on  the  catarrhal  bronchitis 
rather  than  on  the  broncho-pneumonia.  The  sputa  are  swal- 
lowed rather  than  coughed  up.  They  may  collect  in  the  stomach 
and  be  vomited  up. 

The  urine  may  contain  a  little  albumin  and  a  few  casts,  the 
kidneys  being  the  seat  of  acute  degeneration. 

The  physical  signs  vary  with  the  condition  of  tlie  lung.  If 
the  inflammation  is  limited  to  the  walls  of  the  bronchi  and  to 
the  air-spaces  immediately  surrounding  them  there  are  no  phys- 
ical signs.  If  a  catarrhal  bronchitis  is  present  there  are  coarse 
and  subcrepitant  rales.  If  there  is  a  diffuse  pneumonia,  with 
consolidation  of  a  considerable  portion  of  the  lung,  there  are 
dulness  on  percussion  and  bronchial  voice  and  breathing.  If 
there  is  fibrin  on  the  pleura,  there  are  crepitant  or  subcrepitant 
rales.  The  signs  of  tlie  consolidation  and  of  the  pleurisy  are 
usually  developed  between  the  second  and  fifth  days,  but  it  is 
not  uncommon  for  them  to  be  delayed  until  a  much  later  period. 

The  duration  of  broncho-pneumonia  in  children  varies  very 
much  in  different  cases.  Of  the  fatal  cases  the  larger  number 
die  within  two  weeks,  but  some  prove  fatal  within  two  da3'-s,  and 
some  are  protracted  for  seven  or  eight  weeks.  In  the  cases 
which  recover  the  constitutional  symptoms  continue  for  from 
one  to  three  weeks  in  the  majority  of  patients,  but  it  is  bv  no 
means  unusual  for  the  active  symptoms  to  continue  for  six  or 
eight  weeks,  and  yet  the  patients  make  a  perfectly  good  recov- 
ery. Resolution  requires  a  longer  time  than  in  lobar  pneumonia, 
from  seven  to  fourteen  days  in  most  of  the  cases. 

The  Cereb7'al  Cases. — In  many  of  the  cases  of  broncho-pneu- 
monia there  are  cerebral  symptoms — convulsions,  restlessness, 
and  delirium — but  in  some  patients  these  symptoms  are  devel- 
oped to  such  a  degree,  and  are  so  out  of  proportion  to  the  pul- 
monary symptoms,  that  the  cases  require  a  separate  description. 

The  symptoms  resemble  those  of  an  acute  or  a  tubercular 
meningitis.  They  may  begin  and  go  on  acutely,  with  high  fever, 
prostration,  one  or  more  convulsions,  alternating  delirium  and 
stupor.  Or  the  course  is  more  subacute,  loss  of  appetite,  vomit- 
ing, moderate  prostration,  not  very  higli  fever,  alternating  stupor 
and  delirium.  These  symptoms  may  continue  for  from  two  to 
ten  days  before  there  are  any  pulmonary  symptoms.     Then,  as 


PNEUMONIA.  85 

the  pulmonary  symptoms  are  developed,  the  cerebral  symptoms 
subside. 

Persistent  Cases. — If,  after  the  subsidence  of  the  acute  bron- 
cho-pneumonia a  chronic  inflammation  persists,  the  children 
begin  to  improve,  but  yet  do  not  get  well. 

In  some  the  cough  and  the  physical  signs  continue,  the  appe- 
tite is  poor,  the  children  do  not  gain  flesh  and  strength,  but  yet 
they  are  not  sick  in  bed — often  not  confined  to  the  house. 

In  others  the  same  symptoms  exist,  there  is  also  an  irregular 
fever,  and  the  patients  are  sick  in  bed. 

Of  these  protracted  cases  some  recover  entirely  ;  some  re- 
cover with  permanent  consolidation  of  a  portion  of  the  lungs  ; 
some  die  exhausted  by  the  disease  ;  some  go  on  to  have  a  chronic 
interstitial  pneumonia  which  lasts  for  many  years. 

In  some  cases  of  acute  broncho-pneumonia,  the  accompany- 
ing inflammation  of  the  bronchial  glands  may  be  of  tubercular 
character,  and  this  may  serve  at  a  later  period  as  the  focus  of 
infection  which  causes  an  acute  general  tuberculosis. 

Treatment. — If  the  inflammation  is  confined  to  the  walls  of 
^  the  bronchi  and  the  air-spaces  around  them,  counter-irritation  of 
the  wall  of  the  chest  and  antiphlogistic  remedies  are  not  likely 
to  be  of  service.  If,  on  the  other  hand,  catarrhal  bronchitis  and 
general  congestion  of  the  lungs  are  present,  with  rapid  and  la- 
bored breathing,  it  may  be  well  to  use  cups,  or  irritating  lini- 
ments, or  poultices  over  the  chest,  and  to  give  repeated  small 
doses  of  calomel  or  the  sulphate  of  magnesia.  Throughout  the 
disease  good  results  may  be  obtained  from  the  continued  use  of 
ipecac  in  small  doses. 

The  sleeplessness,  restlessness,  and  delirium  are  best  relieved 
by  opium  ;  in  children  who  cannot  take  opium  we  may  use  the 
bromides  or  asafoetida.  The  disposition  to  convulsions  seems  to 
be  lessened  by  the  use  of  the  bromides.  If  the  pulse  is  too  full, 
with  high  temperatures,  the  children  are  made  more  comfortable 
by  the  tincture  of  aconite.  Alcoholic  stimulants  are  not  to  be 
used  unless  there  is  decided  failure  of  the  heart's  action.  The 
feeding  and  nursing  of  the  child  are  of  the  greatest  importance. 

If  resolution  is  delayed,  or  if  the  broncho-pneumonia  persists, 
we  employ  iron,  quinine,  mineral  acids,  oxygen,  cod-liver  oil, 
and  above  all,  change  of  air. 

In  adolescence  the  clinical  picture  of  broncho-pneumonia  is 
the  same  as  it  is  in  children,  but  the  cerebral  symptoms  are  not 


86  PNEUMONIA. 

developed  to  the  same  extent,  and  they  are  more  likely  to  cough 
up  blood. 

In  adults  the  disease  presents  itself  to  us  under  several  differ- 
ent forms  : 

T.  The  patient  has  an  ordinary  attack  of  catarrhal  bronchitis 
lasting  for  several  days.  Instead  of  getting  well  promptly,  how- 
ever, the  patients  continue  to  cough  and  to  feel  sick,  and,  on 
examining  the  chest,  we  find  a  circumscribed  area  where  there 
is  dulness  on  percussion  and  loud,  high-pitched  voice.  This  con- 
solidation of  the  lung  does  not,  however,  last  very  long,  and  the 
patients  make  a  good  recovery. 

2.  The  patients  are  suddenly  attacked  with  a  very  severe  and 
general  broncho-pneumonia.  There  are  chills,  a  rapid  rise  of 
temperature,  headache,  pains  in  the  back  and  chest,  vomiting, 
great  prostration,  a  rapid  pulse  which  soon  becomes  feeble,  very 
bad  breathing — rapid,  labored,  and  insufficient — venous  conges- 
tion of  the  skin  and  of  the  viscera,  cough,  at  first  dry,  then  with 
profuse  mucous  and  blood-stained  sputa,  sleeplessness,  restless- 
ness, and  delirium,  and  albumin  in  the  urine.  There  are  coarse, 
subcrepitant  and  crepitant  rales  over  both  lungs,  sibilant  and 
sonorous  breathing ;  the  percussion-note  is  normal,  or  exagger- 
ated, or  dull.  The  disease  lasts  for  from  seven  to  fourteen  days  ; 
it  is  very  apt  to  prove  fatal. 

Treatment. — The  most  efficient  remedies  are  the  energetic  use 
of  wet  or  dry  cups  over  the  entire  chest,  the  administration  of 
calomel  or  the  sulphate  of  magnesia  in  small  and  repeated  doses, 
ipecac,  the  inhalation  of  oxygen  gas,  and  stimulants, 

3.  There  is  a  form  of  broncho-pneumonia  in  adults  which 
resembles  lobar  pneumonia.  There  is  a  general  catarrhal  bron- 
chitis, with  broncho-pneumonia  and  consolidation  of  one  or  more 
lobes.  The  symptoms  and  physical  signs  are  like  those  of  lobar 
pneumonia,  but  with  some  difference.  The  invasion  of  the  dis- 
ease is  not  as  sudden,  and  the  pulse  is  more  rapid,  the  cerebral 
symptoms  are  more  constant,  the  expectoration  is  like  that  of 
bronchitis,  the  physical  signs  are  more  slowly  developed,  the 
duration  of  the  disease  is  rather  longer  and  resolution  is  slower. 

4.  There  is  a  form  of  broncho-pneumonia  which  resembles 
tubercular  broncho-pneurnonia.  The  invasion  of  the  symptoms 
is  gradual  and  the  disease  is  protracted  over  a  number  of  weeks. 
The  patients  have  more  or  less  cough  and  expectoration,  at  first 
mucous,  later  muco-purulent,  but  not  containing  tubercle  bacilli. 


PNEUMONIA.  87 

There  is  a  moderate  fever,  with  evening  exacerbation  and  sweat- 
ing at  night.  The  physical  signs  are  those  of  bronchitis  and  of 
consolidation  of  circumscribed  portions  of  the  lung.  The  pa- 
tients have  no  appetite  and  lose  flesh  and  strength.  Often  the 
diagnosis  depends  upon  the  examination  of  the  sputa.  After  a 
number  of  weeks  in  some  of  tlie  patients  the  inflammation  sub- 
sides and  a  complete  recovery  is  made,  but  in  others  it  continues 
and  proves  fatal. 

Treatment. — The  patients  are  to  be  kept  in  bed  and  as  well 
fed  as  possible.  The  most  efficacious  treatment  seems  to  be  the 
continued  inhalation  of  the  vapor  of  creosote. 

5.  Persons  suffering  from  emphysema  sometimes  get  up  a 
subacute  broncho- pneumonia,  which  may  prove  fatal. 

6.  Broncho-pneumonia,  especially  of  the  lower  lobes,  is  sec- 
ondary to  the  infectious  diseases,  to  injuries,  to  surgical  opera- 
tions and  to  any  conditions  which  are  likely  to  cause  congestion 
of  the  lungs  and  the  inhalation  of  streptococci. 

The  Pneumonia  of  Heart  Disease. 

Definition. — A  chronic  productive  inflammation  of  the  lungs 
caused  by  chronic  congestion,  and  resulting  in  thickening  of  the 
walls  of  the  air-spaces,  filling  of  their  cavities  with  epithelial 
ceils  and  a  deposition  of  pigment. 

Synonyms. — Brown,  or  pigment,  induration  of  the  lungs. 

Etiology. — Any  long-continued  mechanical  obstruction  to  the 
escape  of  the  blood  from  the  lungs  into  the  left  cavities  of  the 
heart  can  produce  this  form  of  pneumonia.  The  most  frequent 
and  effectual  obstruction  is  furnished  by  a  stenosis  of  the  mitral 
valves  ;  but  any  valvular  lesion  of  the  heart,  dilatation  of  the 
ventricles,  or  aneurism  of  the  arch  of  the  aorta  may  act  in  the 
same  way. 

Morbid  Anatomy. — The  first  effect  of  the  obstruction  to  the 
circulation  seems  to  be  a  change  in  the  capillary  vessels  in  the 
walls  of  the  air-spaces.  These  vessels  become  dilated,  tortuous, 
and  have  their  walls  thickened.  Then  there  is  a  gradual  thick- 
ening and  pigmentation  of  the  walls  of  the  air-spaces  ;  an  in- 
crease in  the  size  and  number  of  the  epithelial  cells,  until  they 
partly  or  completely  fill  the  cavities  of  the  air-spaces  ;  an  escape 
of  the  red  blood-cells  into  the  air-spaces.  Finally,  when  the  in- 
flammation has  reached  its  full  development,  there  is  a  smooth. 


88  PNEUMONIA. 

red  hepatization  of  portions  of  both  lungs,  an  hepatization  due 
principally  to  the  filling  of  the  air-spaces  with  epithelial  cells. 

The  lungs  are  diminished  in  size,  sometimes  covered  with  old 
adhesions,  but  seldom  with  fibrin.  There  may  be  more  or  less 
serum  of  dropsical  character  in  the  pleural  cavities.  The  texture 
of  the  lungs  is  leathery  and  dense,  or  that  of  a  smooth  hepatiza- 
tion. They  are  dry,  of  a  salmon-pink  color  mottled  with  brown 
or  black.  There  may  be  large  or  small  areas  where  the  air- 
spaces are  filled  with  extravasated  blood. 

Symptoms. — The  principal  symptoms  exhibited  by  the  patients 
are  those  due  to  the  lesions  of  the  heart  or  aorta.  The  changes 
in  the  lungs  do  not  give  as  marked  symptoms  as  might  be  ex- 
pected. The  physical  signs  are  obscure — more  or  less  dulness 
and  diminished  breathing.  The  rational  symptoms  are — -dysp- 
noea, cough,  mucous  and  bloody  sputa,  the  continued  expec- 
toration of  pure  blood. 

Treatment. — It  is  evident  that  this  condition  of  the  lungs  is 
one  which  cannot  be  influenced  by  treatment.  We  simply 
attend  as  well  as  we  can  to  the  disturbances  of  circulation  which 
have  caused  the  lung  trouble. 

■'  Interstitial  Pneumonia. 

Definition. — A  chronic  productive  inflammation,  which  in- 
volves the  connective-tissue  framework  of  the  lung  and  the  walls 
of  the  air-spaces,  and  results  in  the  formation  of  new  connective 
tissue  and  obliteration  of  the  air-spaces. 

Etiology. — The  well-marked  examples  of  interstitial  pneu- 
monia follow  acute  lobar  pneumonia  with  the  production  of  new 
connective  tissue  ;  broncho-pneumonia;  chronic  pleurisy  with 
adhesions  ;  chronic  bronchitis,  and  the  inhalation  of  the  dust  of 
coal,  or  of  stone. 

Morbid  Anatomy. — The  condition  of  the  lungs  varies  with  the 
cause  of  the  interstitial  pneumonia. 

(i.)  If  it  follows  acute  lobar  pneumonia  with  the  production 
of  new  connective  tissue,  one  lobe,  or  an  entire  lung,  is  covered 
with  pleuritic  adhesions,  it  is  small,  smooth,  and  dense  ;  the  air- 
spaces and  small  bronchi  are  obliterated  by  the  new  connective 
tissue. 

(2)  If  it  follows  broncho-pneumonia,  one  or  more  lobes  are 
studded  with  fibrous  nodules,  or  are  converted  into  dense  fibrous 


PNEUMONIA.  89 

tissue.     The   pleura  is   thickened,  tiie  bronchi  are  inflamed  and 
often  dilated. 

(3)  If  it  follows  thickening  of  the  pleura,  bands  of  connective 
tissue  extend  from  the  pleura  into  the  lung,  the  bronchi  are  in- 
fiamed  and  often  dilated, 

(4)  If  it  follows  chronic  bronchitis  there  are  fibrous  nodules 
around  the  bronchi,  with  more  or  less  diffuse  connective  tissue. 

(5)  If  it  is  due  to  the  inhalation  of  the  dust  of  coal  or  stone, 
we  find  in  both  lungs  fibrous  peribronchitic  nodules  and  diffuse 
connective  tissue. 

In  most  of  the  cases  the  portions  of  lung  exempt  from  the  in- 
terstitial pneumonia  are  em.physematous. 

Syrnpioms. — The  patients  have  a  cough  with  mucous  expecto- 
ration. The  cough  becomes  more  constant  and  troublesome  as 
the  disease  progresses.  The  expectoration  becomes  muco-puru- 
lent,  sometimes  fetid.  If  the  bronchi  become  dilated,  the  muco- 
pus  accumulates  in  them  and  is  coughed  up  at  intervals  in  large 
quantities.  There  may  be  occasional  haemoptyses.  There  is 
dyspnoea  on  exertion,  at  first  slight,  later  more  marked.  There 
may  be  uncomfortable  feelings  or  actual  pain  over  the  affected 
side  of  the  chest.  There  is  gradual  loss  of  flesh  and  of  strength. 
Neither  laryngitis  nor  diarrhoea  belong  to  the  disease.  There  is 
no  fever  except  with  exacerbations  of  the  bronchitis. 

The  affected  side  of  the  chest  is  retracted,  the  other  side  is 
enlarged,  the  heart  is  displaced,  the  vertebral  column  is  curved 
laterally.  There  is,  on  percussion,  dulness,  or  flatness,  or  tym- 
panitic resonance.  The  vocal  fremitus  is  increased.  The  breath- 
ing is  sonorous,  sibilant,  bronchial,  cavernous,  or  amphoric,  ac- 
cording to  the  condition  of  the  bronchi  and  the  degree  of  con- 
solidation of  the  lung.  There  are  pleuritic  creaking  sounds, 
subcrepitant,  coarse,  or  gurgling  rales. 

The  disease  is  one  which  lasts  for  many  years,  and  the  pa- 
tients usually  die  with  some  acute  inflammation  of  the  other 
healthy  lung. 

Treatment. — The  most  efficient  treatment  is  that  the  patient 
should  reside  permanently  in  a  climate  where  he  is  able  to  live 
out  of  doors,  and  where  his  bronchitis  does  well. 

If  this  cannot  be  done,  we  attend  to  the  bronchitis  and  the  nu- 
trition of  the  patient  as  well  as  we  can. 


90  MILIARY   TUBERCULOSIS. 

Tubercular  Pneumonia. 

Defifiition. — Under  this  name  we  include  all  the  inflamma- 
tions of  the  lung  which  are  accompanied  with  the  growth  of 
tubercle  bacilli.  Of  such  inflammations  there  are  a  number 
which  differ  from  each  other  widely  in  their  morbid  anatomy 
and  clinical  symptoms.  We  are  not  at  the  present  time  provided 
with  satisfactory  names  to  designate  these  different  forms  of 
tubercular  pneumonia,  so  that  we  still  have  to  use  the  old  arbi- 
trary terms  to  which  there  are  so  many  objections. 

We  distinguish,  therefore  : 

Acute  miliary  tuberculosis  of  the  lungs. 

Chronic  miliary  tuberculosis  of  the  lungs. 

Acute  pulmonary  phthisis. 

Chronic  pulmonary  phthisis. 

Acute  Miliary  Tuberculosis  of  the  Lungs. 

Definition. — A  tubercular  inflammation  of  the  lungs  character- 
ized by  the  presence  of  a  number  of  small  foci  of  inflammation, 
of  which  the  inflammatory  products  form  very  small  nodules, 
called  miliary  tubercles.  The  tubercular  inflammation  may  be 
confined  to  the  lungs,  or  it  may  be  part  of  a  general  tuber- 
culosis. 

Etiology. — For  the  development  of  tubercular  inflammation  in 
any  part  of  the  body  there  are  necessary  :  the  proper  predispo- 
sition of  the  individual,  a  local  cause  of  inflammation,  and  the 
growth  of  tubercle  bacilli.  In  the  lungs  the  tubercle  bacilli  seem 
to  be  either  inhaled  or  brought  to  the  lungs  by  the  blood.  It  is 
possible  that  the  bacilli  may  be  first  inhaled,  then  collected  in 
the  bronchial  glands,  and  from  the  glands  find  their  way  into  the 
pulmonary  circulation.  Certainly,  we  see  cases  in  which  tuber- 
cular inflammation  of  the  bronchial  glands  precedes  miliary 
tuberculosis  of  the  lungs.  The  bacilli  which  are  inhaled  must 
be  derived  to  some  extent  from  the  dried  sputa  of  persons  who 
have  tubercular  pneumonia.  The  bacilli  a;re  much  more  abun- 
dant in  the  air  of  some  localities  than  of  others,  and  at  high  alti- 
tudes and  on  the  ocean  the  air  contains  none  of  these  organisms. 
The  bacilli  which  are  conveyed  to  the  lungs  by  the  blood  are 
derived  from  a  focus  of  tubercular  inflammation  in  some  other 
parts  of  the  body.     In  man  tuberculosis  is  conveyed  by  inocula- 


MILIARY   TUBERCULOSIS.  91 

tion  from  one  person  to  another  only  in  rare  cases.  In  some 
animals  tuberculosis  can  be  inoculated  at  will,  and  miliary  tuber- 
cles of  the  lungs  easily  produced.  Trudeau,  however,  has  shown 
that  the  success  of  such  an  inoculation  can  be  influenced  by  en- 
vironment, and  that  it  is  possible  to  keep  rabbits  under  such 
conditions  of  good  health  that  they  cease  to  offer  a  good  soil  for 
the  growth  of  tubercle  bacilli.  The  most  perfect  miliary  tuber- 
cles in  the  lungs  of  animals  which  I  have  ever  seen,  are  those 
produced  by  injections  of  dead  tubercle  bacilli  into  the  trachea 
of  rabbits  (Prudden). 

Morbid  Anatomy. — The  miliary  tubercles  may  be  confined  to 
part  of  a  lung,  or  be  distributed  through  both  lungs.  They  are 
close  together,  or  separated  by  considerable  intervals,  or  aggre- 
gated together  into  larger  masses.  They  are  of  gray,  white,  or 
yellow  color.  They  all  contain  tubercle  bacilli,  but  these  bodies 
are  much  more  numerous  in  some  tubercles  than  they  are  in 
others.     They  are  composed  of  : 

1.  Groups  of  air-passages  and  air-vesicles  filled  with  granular 
matter,  pus-cells,  and  epithelium. 

2.  Groups  of  air-passages  and  air-vesicles  of  which  the  walls 
are  infiltrated  with  tubercle  tissue,  while  their  cavities  are  filled 
either  with  tubercle  tissue  or  with  epithelium,  pus,  and  fibrin. 

3.  Infiltrations  of  the  walls  of  small  bronchi  with  tubercle 
tissue,  or  round-celled  tissue,  the  infiltration  extending  to  the 
walls  of  the  adjacent  air-spaces. 

4.  Nodules  of  tubercle  tissue  situated  in  the  pulmonary  pleura, 
the  septa  between  the  lobules,  the  walls  of  the  bronchi,  and  the 
walls  of  the  veins. 

In  addition  to  the  presence  of  the  miliary  tubercles  the  bron^ 
chi  are  congested  and  coated  with  mucus,  the  walls  of  the  air- 
spaces are  congested,  the  epithelial  cells  which  line  them  are  in- 
creased in  size  and  number,  some  of  the  air-spaces  are  filled  with 
epithelium,  fibrin,  and  pus  ;  there  may  be  fibrin  on  the  pul- 
monary pleura. 

Symptoms. — i.  The  method  of  infection  may  be  such  that  an 
enormous  number  of  miliary  tubercles  are  at  once  formed  in  the 
lungs  and  in  other  parts  of  the  body,  the  poisonous  effects  of  the 
chemical  substances  produced  by  the  growth  of  the  tubercle 
bacilli  are  very  marked,  and  the  patients  behave  as  if  they  had  a 
general  disease  rather  than  an  inflammation  of  the  lungs. 

Although  the  lungs  are  congested  and  thickly  studded  with 


92  MILIARY   TUBERCULOSIS. 

miliary  tubercles  the  physical  signs  are  not  as  constant  or  as 
plain  as  one  would  wish  them  to  be.  The  changes  in  the  percus- 
sion-note are  not  well  marked.  There  may  or  may  not  be  some 
dulness.  Crepitant  or  subcrepitant  or  coarse  rales,  bronchial 
voice  and  breathing,  or  rude  breathing  are  sometimes  present, 
sometimes  absent.  Moreover  the  physical  signs  may  be  modified 
by  the  existence  of  old  tubercular  lesions  in  the  lungs.  The 
rational  pulmonary  symptoms  also  are  not  constant.  Cough  and 
mucous  sputa,  rapid  and  oppressed  breathing,  and  pain  over  the 
chest  are  present  in  some  cases,  absent  in  others. 

The  temperature  rises  rapidly  and  is  between  ioo°  and  107°  F. 
throughout  the  disease.  The  pulse  and  heart  action  become 
more  rapid  and  feeble  as  the  disease  progresses.  The  tongue  is 
coated  and  soon  becomes  brown  and  dry.  There  is  loss  of  appe- 
tite, nausea,  and  sometimes  vomiting.  The  bowels  remain  regu- 
lar, or  are  constipated,  or  loose.  Sooner  or  later  alternating 
stupor  and  delirium,  extreme  emaciation  and  the  typhoid  state 
are  developed.  The  disease  m.ay  last  for  only  a  few  days,  or  for 
three  or  four  weeks.  So  far  as  I  know  it  always  terminates 
fatally. 

2.  The  method  of  infection  is  such  that  miliary  tubercles  are 
formed  only  in  part  of  a  lobe,  or  are  distributed  through  an  en- 
tire lobe,  or  the  whole  of  one  lung,  or  a  large  part  of  both  lungs. 
But  there  are  no  tubercles  outside  of  the  lungs,  it  is  a  localized 
tubercular  inflammation. 

Etiology. — This  condition  may  be  developed  at  any  time  in  a 
person  who  has  the  tubercular  disposition,  and  we  are  seldom 
certain  in  such  cases  as  to  the  exciting  cause  of  the  inflamma- 
tion or  the  exact  method  of  the  infection.  It  is  also  of  frequent 
occurrence  in  persons  who  already  have  a  chronic  tubercular  in- 
flammation of  some  part  of  the  lung.  In  such  cases  it  is  proba- 
ble that  the  infection  comes  from  the  old  tubercular  lesion. 

Morbid  Anatomy. — As  the  disease  runs  rather  a  subacute  than 
an  acute  course  the  tubercles  are  firmer  and  more  regularly  com- 
posed of  tubercle  tissue  than  is  the  case  in  acute  general  tuber- 
losis.  The  most  frequent  position  of  the  tubercles  is  at  the  apex 
of  one  lung,  but  they  may  be  localized  at  any  part  of  the  lungs. 
It  is  not  often  that  the  whole  of  both  lungs  is  involved.  The 
cases  vary  greatly  as  to  the  extent  of  the  associated  bronchitis, 
pleurisy,  and  exudative  pneumonia.  The  bronchitis  may  be  con- 
fined to  the  portion  of  the  lung  which  contains  the  miliary  tuber- 


MILIARY   TUBERCULOSIS.  93 

cles,  or  it  may  be  a  general  bronchitis  involving  the  larger  tubes 
in  both  lungs.  The  pleurisy  is  either  with  j5brin  alone,  or  with 
large  quantities  of  serum  in  the  pleural  cavity.  The  exudative 
pneumonia  may  involve  only  small  portions  of  the  lung,  or  an 
entire  lobe  may  be  consolidated. 

Syfnptoms. — These  are  in  proportion  to  the  extent  of  lung  in- 
volved. If  only  a  part  of  one  lung  is  involved  the  other  symp- 
toms are  often  preceded  by  one  or  more  haemoptyses.  When 
the  disease  is  established  the  patients  suffer  from  : 

1.  A  febrile  movement  which  is  regularly  higher  in  the  after- 
noon and  followed  by  sweating  at  night.  The  fever  may  be  con- 
fined to  the  afternoon,  with  normal  morning  temperatures.  The 
height  of  the  temperature  varies  with  the  extent  of  lung  involved, 
the  severity  of  the  associated  bronchitis,  pleurisy,  or  pneumo- 
nia, the  character  of  the  patient,  and,  probably,  the  quantity  of 
poisonous  products  which  are  evolved  by  the  growth  of  the 
bacteria. 

2.  An  increased  frequency  of  the  heart  action.  This  is  a  very 
constant  symptom,  so  constant  that  whenever  we  find  a  patient 
with  a  rapid  pulse  for  which  there  is  no  evident  cause  we  must 
always  think  of  the  possibility  of  a  tubercular  inflammation  of 
the  lungs. 

3.  The  breathing  is  often  increased  in  frequency  and  some- 
times labored  even  with  lesions  of  small  extent.  It  is  made 
worse  by  an  extension  of  the  tuberculosis,  or  by  the  development 
of  bronchitis,  pleurisy,  or  pneumonia. 

4.  Most  of  the  patients  have  more  or  less  cough.  They  may 
only  cough  in  the  morning,  or  throughout  the  day,  or  in  severe 
attacks,  which  may  provoke  vomiting.  In  some  patients  the 
cough  is  hardly  noticeable,  in  others  it  is  the  most  distressing 
feature  of  the  disease.  The  immediate  cause  of  the  cough  is  not 
always  the  same.  It  may  be  principally  due  to  a  catarrhal  pharyn- 
gitis, or  to  the  bronchitis,  or  to  the  pleurisy.  How  far  the  pres- 
ence of  the  tubercles  in  the  lungs  causes  cough  is  difficult  to  say. 
In  some  persons  the  cough  is  evidently  largely  hysterical,  out  of 
all  proportion  to  any  real  reason  for  it.  The  expectoration,  if 
there  is  any,  is  mucous,  or  muco-purulent  in  character.  It  often, 
but  not  always,  contains  tubercle  bacilli.  There  may  be  small 
haemoptyses  throughout  the  course  of  the  disease. 

5.  Loss  of  appetite  with  more  or  less  nausea.  This  is  present 
in  a  great  many  of  the  patients.     It  is  a  serious  matter,  for  it  is 


94  MILIARY   TUBERCULOSIS. 

one  reason  for  their  loss  of  flesh  and  strength.  Actual  vomiting 
usually  occurs  only  after  fits  of  coughing. 

6.  Loss  of  flesh  and  strength  are  characteristic  symptoms, 
but  they  are  not  always  in  proportion  to  the  extent  of  lung 
involved.  We  must  judge  of  the  real  condition  of  the  patient 
rather  by  the  pulmonary  lesions  than  by  the  general  condition. 

It  is  questionable  whether  the  miliary  tubercles  alone  give  any 
physical  signs.  And  as  a  matter  of  fact  many  patients  who  have 
acute  miliary  tuberculosis  give  no  physical  signs  at  all.  But  the 
associated  bronchitis,  pleurisy,  and  pneumonia  do  give  physical 
signs.  The  bronchitis  gives  coarse  and  subcrepitant  rales  ;  the 
pleurisy,  dulness,  friction  sounds,  crepitant  and  subcrepitant 
rales  ;  the  pneumonia,  dulness,  increased  vocal  resonance,  bron- 
chial voice,  and  bronchial  breathing. 

(i)  When  the  disease  is  once  established  it  may  continue  for 
a  number  of  months,  the  inflammation  then  subsides,  and  the  pa- 
tients recover  altogether. 

(2)  Or,  the  inflammation  may  remain  localized  but  will  become 
chronic,  and  the  patients  go  on  with  the  history  of  chronic  miliary 
tuberculosis. 

(3)  Instead  of  this  the  tubercular  inflammation,  after  remain- 
ing for  months  circumscribed,  will  either  continuously,  or  at 
intervals,  extend  and  involve  more  and  more  of  the  lungs.  When 
this  is  the  case  the  patients  get  worse  either  continuously,  or  with 
intervals  of  improvement. 

(4)  In  some  cases  there  are  one  or  several  intercurrent  attacks 
of  bronchitis,  pleurisy,  or  pneumonia  so  severe  as  to  modify  the 
course  of  the  disease.  With  each  attack  of  this  kind  the  temper- 
ature runs  up,  the  physical  signs  change,  and  the  patient  is  evi- 
dently more  seriously  ill. 

(5)  If  both  lungs  are  at  the  first  involved  by  the  tubercular 
inflammation,  the  patients  have  the  same  symptoms  but  in  a  more 
severe  form.  They  lose  flesh  and  strength  rapidly,  develop  alter- 
nating delirium  and  stupor,  pass  into  the  typhoid  condition,  and 
die  within  a  few  weeks. 

Treatment. — If  both  lungs  are  involved  in  the  morbid  process 
treatment  is  of  no  avail.  But  if  only  a  part  of  one  lung  is  dis- 
eased, the  patients  can  be  much  benefited  by  proper  management 
— the  two  essential  points  in  the  treatment  being  that  the  patients 
should  eat  enough  food,  and  live  in  a  proper  climate. 

As  regards  the  feeding,  it  is  important  that  the  patients  should 


MILIARY   TUBERCULOSIS.  95 

take  fat  in  some  form  in  addition  to  the  other  articles  of  diet.  In 
some  patients  a  proper  climate  alone  will  improve  the  appetite  ; 
in  others,  it  may  be  necessary  to  use  bitters,  alkalies,  or  mineral 
acids,  to  relieve  constipation,  to  wash  out  the  stomach,  or  to  feed 
through  tlie  stomach-tube.  Generally  speaking,  all  the  prepared 
and  peptonized  foods  and  extracts  are  to  be  avoided.  The  pa- 
tients do  best  with  milk,  cream,  meats,  vegetables,  fruits,  and 
breadstuffs. 

As  regards  climate,  I  doubt  if  there  is  any  one  place  suitable 
for  all  the  patients.  The  idiosyncracy  of  each  person  must  be 
considered,  and  we  find  that  some  do  best  on  the  sea- shore,  some 
in  the  interior,  some  in  a  warm  climate,  some  in  a  cold  climate, 
while  some  do  best  if  they  travel  from  place  to  place. 

Chronic  Miliar\  Tuberculosis. 

Definitioti. — A  chronic  tubercular  inflammation  of  the  lungs 
characterized  by  the  formation  of  miliary  tubercles,  to  which 
may  be  added  bronchitis,  dilatation  of  the  bronchi,  pleurisy,  in- 
terstitial pneumonia,  and  emphysema. 

Etiology. — It  seems  to  be  necessary  to  suppose  in  these  cases  : 
a  predisposition,  an  exciting  cause  for  inflammation,  and  the 
growth  of  tubercle  bacilli.  It  is  evident,  however,  that  the  mode 
and  character  of  the  infection  must  differ  from  those  of  acute 
miliary  tuberculosis.  The  structure  of  the  tubercles  is  differ- 
ent, they  contain  very  few  tubercle  bacilli,  and  the  other  morbid 
changes  in  the  lungs  may  be  of  more  importance  than  are  the 
tubercles. 

Mo7'bid  Anatomy. — The  morbid  process  begins  regularly  at  the 
apex  of  one  of  the  lungs,  and  then  slowly  extends  either  progres- 
sively or  in  attacks,  until  a  larger  portion  of  the  lungs  is  in- 
volved. 

In  the  simplest  form  of  the  disease  the  only  change  in  the 
lungs  is  the  formation  of  miliary  tubercles.  These  tubercles  are 
harder  and  denser  than  are  those  which  are  found  with  acute 
tuberculosis.  They  are  composed  of  tubercle  tissue,  or  round- 
celled  tissue,  or  connective  tissue,  or  are  in  the  condition  of 
cheesy  degeneration.     They  contain  but  few  tubercle  bacilli. 

Another  simple  form  of  the  disease  is  when  miliary  tubercles 
alone  are  formed  in  lungs  which  are  already  the  seat  of  vesicular 
emphysema. 


96  MILIARY   TUBERCULOSIS. 

Usuall}',  however,  in  addition  to  the  miliary  tubercles  there 
are  other  changes  in  the  lungs.  These  additional  lesions  begin 
in  the  same  part  of  the  lung  where  the  tubercles  are  formed,  and 
accompany  the  development  of  the  tubercles  in  fresh  parts  of  the 
lungs. 

(i)  There  may  be  a  localized  catarrhal  bronchitis. 

{2)  There  may  be  an  inflammation  of  the  walls  of  the  bronchi 
with  partial  destruction  of  these  walls,  and  the  formation  of  cyl- 
indrical or  sacculated  bronchiectasiae.  The  walls  of  the  cavities 
thus  formed  may  be  converted  into  connective  tissue,  or  they  may 
remain  suppurating  and  necrotic. 

(3)  There  may  be  an  interstitial  pneumonia  with  the  produc- 
tion of  new  connective  tissue,  the  obliteration  of  the  air-spaces, 
and  tlie  consolidation  of  portions  of  the  lung. 

(4)  There  may  be  dilatation  of  the  air-spaces  of  the  portions 
of  the  lungs  which  are  not  consolidated. 

(5)  There  may  be  thickening  of  the  pulmonary  and  costal 
pleura,  with  connective-tissue  adhesions. 

(6)  While  the  morbid  process  begins  as  a  localized  tubercular 
inflammation  of  the  lung,  and  often  retains  throughout  this  local 
character,  yet  it  may  also  happen  that  from  this  local  lesion  other 
parts  of  the  body  may  be  infected.  Tubercular  laryngitis,  and 
tubercular  inflammation  of  the  solitary  and  agminated  glands  of 
the  small  intestine,  often  complicate  the  pulmonary  lesion,  and 
sometimes  even  acute  general  tuberculosis  is  produced. 

Sympto7ns. — The  disease  may  follow  an  acute  pulmonary  tuber- 
culosis, or  it  may  be  chronic  from  the  outset.  There  is  such  a  very 
great  difference  in  the  behavior  of  the  disease  in  different  per- 
sons, that  it  is  necessary  to  arrange  the  cases  into  a  number  of 
groups  according  to  the  character  of  the  lesions  and  the  symp- 
toms. 

1.  There  seems  good  reason  to  believe  that  a  small  tubercular 
inflammation  of  one  apex  often  runs  its  course  and  terminates  in 
recovery,  without  ever  giving  symptoms  of  sufficient  severity  to 
attract  the  attention  of  the  patient,  or  lead  him  to  consult  a 
physician, 

2.  There  are  patients  who  suffer  for  some  time  fi'om  pulmo- 
nary emphysema  with  its  attendant  symptoms.  In  them  miliary 
tubercles  are  formed  in  the  lungs  and  slowly  increase  in  number, 
but  are  not  accompanied  with  the  growth  of  much  connective  tis- 
sue, and  are  scattered  at  some  distance  from  each  other  through 


MILIARY   TUBERCULOSIS.  97 

the  lungs.  The  formation  of  the  tubercles  does  not  change  the 
physical  signs  belonging  to  the  emphysema  which  the  patient 
already  has.  The  ordinary  rational  symptoms  of  emphysema 
continue  unchanged,  but  the  patients  lose  flesh  and  strength 
rapidly,  and  finally  die  very  much  emaciated.  It  is  very  difficult 
to  distinguish  these  cases  from  the  bad  cases  of  emphysema  with- 
out tuberculosis. 

3.  A  very  common  form  of  the  disease  is  that  in  which  the 
inflammation  is  confined  to  one  or  both  apices,  continues  for 
some  time,  subsides,  and  the  patient  recovers. 

In  these  cases  the  first  symptom  may  be  one  or  more  small  or 
large  hsemoptyses.  Before  the  bleeding  the  patients  have  had 
no  pulmonary  symptoms,  but  after  the  bleeding  these  symptoms 
are  gradually  developed. 

Or  the  first  symptom  may  be  a  troublesome  cough  with  little 
or  no  expectoration.  This  cough  at  first  does  not  seem  of  much 
consequence,  but  it  continues  in  spite  of  all  remedies. 

Or  the  patients  simply  lose  flesh  and  strength  without  any 
evident  reason  for  this  loss  of  nutrition.  The  pulse  is  also  in- 
creased in  frequency,  but  for  a  time  there  are  no  pulmonary 
symptoms. 

At  this  early  stage  of  the  disease  there  may  be  no  physical 
signs. 

As  the  disease  goes  on  the  patients  have  more  or  less  cough, 
which  troubles  them  only  in  the  morning,  or  occurs  in  attacks, 
or  is  persistent  and  troublesome  through  the  whole  day.  There 
may  be  no  expectoration.  When  present  the  sputa  are  mucous 
or  muco-purulent,  not  abundant,  and  often  contain  tubercle  ba- 
cilli. There  is  some  dyspnoea  on  exertion.  Some  of  the  patients 
complain  of  a  great  deal  of  pain  over  the  inflamed  lung,  others 
have  no  pain  at  all.  Haemoptyses  may  be  repeated  at  any  time, 
and  are  apt  to  be  followed  by  an  increase  in  the  severity  of  the 
s\'mptoms.  The  frequency  of  the  pulse  is  increased  in  nearly  all 
the  patients.  A  febrile  movement  is  not  a  prominent  symptom, 
there  may  be  afternoon  temperatures  of  100°  F.  followed  by  sweat- 
ing, but  often  during  much  of  the  time  there  is  no  fever  at  all. 
The  appetite  is  poor,  nausea  and  vomiting  are  often  troublesome. 
The  patients  lose  flesh  and  strength.  In  some  cases  the  svmp- 
toms  are  not  at  any  time  severe  ;  in  others  the  constitutional  dis- 
turbances are  so  out  of  proportion  to  the  lesion  as  to  indicate 
systemic  infection. 


98  MILIARY   TUBERCULOSIS. 

The  physical  signs  become  more  marked  with  the  further 
development  of  the  thickening  of  the  pleura,  the  formation  of 
miliary  tubercles,  the  growth  of  interstitial  connective  tissue,  the 
localized  bronchitis,  and  the  dilatation  of  the  bronchi.  So  we 
find  :  retraction  of  the  chest-wall  above  and  below  the  clavicle, 
the  percussion  sound  of  higher  pitch  and  of  shorter  duration 
above  and  below  the  clavicle,  subcrepitant  rales,  friction  sounds, 
a  higher  pitched  and  louder  voice,  the  breathing  diminished,  or 
of  altered  quality,  or  with  prolonged  expiration. 

Such  a  circumscribed  tubercular  inflammation  usually  con- 
tinues for  a  year,  sometimes  longer,  then  it  subsides  and  the 
patients  recover.  The  portion  of  lung  which  has  been  inflamed 
is  left  permanently  changed  into  connective  tissue. 

As  the  patient  has  had  one  attack  of  tubercular  inflammation, 
so,  although  he  has  entirely  recovered  from  this  attack,  he  may 
have  subsequent  attacks  of  tlie  same  kind.  In  some  of  the  pa- 
tients, after  the  subsidence  of  the  inflammation,  tubercle  bacilli 
are  left  in  the  portion  of  lung  which  has  been  inflamed.  These 
may  at  any  time  later  serve  as  a  source  of  infection  for  a  new 
local  or  general  tuberculosis. 

4.  The  tubercular  inflammation,  beginning  at  the  apex  of  one 
lung,  gradually  extends  and  involves  a  large  part  of  both  lungs. 
The  pleuritic  adhesions  become  more  extensive,  a  larger  number 
of  bronchi  are  involved  in  tlie  catarrhal  bronchitis,  miliary  tuber- 
cles and  new  connective  tissue  replace  more  and  more  of  the 
lung  tissue.  The  changes  in  the  walls  of  the  bronchi  and  of  the 
lung  surrounding  them  result  in  the  formation  of  bronchiectatic 
cavities,  which  constantly  increase  in  size,  and  the  walls  of  which 
are  necrotic  or  suppurating.  As  the  disease  progresses,  therefore, 
the  patients  suffer,  not  only  from  the  infection  due  to  the  tuber- 
cular inflammation,  but  also  from  that  due  to  the  necrosis  and 
suppuration  of  the  walls  of  cavities,  while  in  addition  more  and 
more  of  the  lungs  is  rendered  unfit  for  breathing. 

The  physical  signs  of  consolidation  and  of  pleuritic  adhesions 
become  more  marked,  and  as  the  cavities  are  formed  and  increase 
in  size  their  physical  signs  are  added. 

The  cough,  which  depends  at  first  upon  the  bronchitis  or  the 
pleurisy,  is  made  worse  by  the  formation  of  bronchiectasife. 
The  expectoration  becomes  more  profuse,  more  purulent  and 
contains  portions  of  dead  lung.  Bacilli  are  present,  in  the 
sputum  in  larger  numbers.     The  difficulty  in  breathing  becomes 


MILIARY   TUBERCULOSIS.  99 

more  troublesome.  The  patients  differ  very  much  as  to  the 
presence  or  absence  of  pain  in  the  cliest.  Either  large  or  small 
haemoptyses  may  be  repeated  at  any  time.  At  first  the  blood 
comes  from  the  mucous  membrane  of  tlie  bronchi,  but  after 
cavities  have  been  formed  there  may  be  bleeding  from  eroded 
vessels  in  their  walls.  This  bleeding  is  apt  to  be  profuse,  con- 
tinuous, and  often  fatal.  The  pulse  continues  to  be  rapid 
through  the  greater  part  of  the  disease.  The  fever  becomes 
higher  and  more  continuous  as  the  disease  progresses,  especially 
after  the  formation  of  cavities.  The  appetite  is  poor  and  nausea 
and  vomiting  are  often  troublesome.  In  women  menstruation 
becomes  irregular  or  ceases  altogether.  The  patients  get  worse 
from  year  to  year,  but  often  with  periods  of  improvement,  and 
the  whole  duration  of  the  disease  is  apt  to  be  very  considerable. 
After  a  time  in  many  of  the  patients  a  tubercular  inflamma- 
tion of  the  larynx  or  of  the  agminated  glands  of  the  small  intes- 
tines is  added  and  then  the  loss  of  flesh  and  strength  are  much 
more  rapid. 

5.  There  are  cases  in  which  the  tubercular  inflammation 
gradually  extends  until  the  whole  of  both  lungs  are  thickly 
studded  with  miliary  tubercules  and  in  addition  there  are  exten- 
sive pleuritic  adhesions,  but  there  is  little  diffuse  fibrous  tissue, 
little  or  no  bronchitis,  and  no  dilatation  of  the  bronchi. 

The  clinical  history  of  these  patients  is  very  misleading. 
They  have  no  cough,  no  haemoptysis,  no  pulmonary  symptoms, 
no  fever.  There  are  no  physical  signs  except  those  belonging 
to  the  pleuritic  adhesions.  But  very  often  the  functions  of  the 
stomach  and  intestine  are  much  disordered.  The  most  striking 
symptom  of  these  patients  is  their  emaciation.  This  goes  on 
steadily  until  the  patients  are  mere  skeletons,  looking  as  if  they 
were  starving  to  death  with  a  cancer  of  the  stomach.  And  yet 
they  may  really  be  taking  and  retaining  a  considerable  quantity 
of  food.  But  in  spite  of  the  food  they  continue  to  lose  flesh  as 
if  the}'-  had  a  malignant  disease.  The  diagnosis  of  these  cases  is 
often  extremely  difficult. 

6.  There  are  cases  in  which  a  tubercular  laryngitis  is  respon- 
sible for  most  of  the  symptoms,  the  lesions  in  the  lungs  being 
inconsiderable.  The  upper  part  of  the  larynx  and  the  epiglottis 
are  the  portions  usually  involved.  There  is  first  a  formation  of 
tubercle  granula  here  and  there  in  the  stroma  of  the  mucous 
membrane  witli   more  or   less  catarrhal  inflammation.     After  a 


lOO  MILIARY   TUBERCULOSIS. 

time  the  tubercle  granula  and  the  mucous  membrane  over  them 
become  necrotic,  soften,  slough,  and  form  ulcers.  These  ulcers 
do  not  heal,  but  rather  increase  in  size,  their  floors  and  walls 
being-  formed  partly  of  tubercle,  partly  of  round-celled  tissue. 
The  mucous  membrane  left  between  the  ulcers  is  thickened  and 
the  seat  of  chronic  catarrhal  inflammation. 

With  such  a  tubercidar  laryngitis  the  patients  have  a  cough 
with  muco-purulent  expectoration,  a  changed  voice,  and  some- 
times laryngeal  dyspnoea.  But  the  thing  whicli  troubles  them 
the  most  is  the  pain  in  the  throat,  which  is  made  worse  by  swal- 
lowing. This  may  interfere  seriously  with  the  feeding  of  the 
patient. 

The  patients  lose  flesh  and  strength,  but  are  not  confined  to 
bed.  Indeed,  many  years  may  pass  before  the  pulmonary  tuber- 
culosis gives  much  trouble. 

7.  In  a  few  cases  a  very  small  miliary  tuberculosis  of  the  lung 
is  complicated  with  an  extensive  tubercular  inflammation  of  the 
small  intestine. 

These  patients  have  a  little  cough,  and  perhaps  the  physical 
signs  of  a  small  consolidation  at  one  apex.  It  is  important  to 
remember  that  they  do  not  necessarily  have  diarrhoea.  But  they 
lose  flesh  and  strength  with  a  rapidity  which  the  pulmonary  con- 
ditions do  not  account  for. 

P7'ognosis. — In  the  early  periods  of  the  disease,  with  little 
evidence  of  systemic  infection,  we  may  often  expect  the  complete 
recovery  of  the  patient.  As  more  of  the  lungs  is  involved,  as 
cavities  are  formed,  as  the  complicating  laryngitis  and  enteritis 
are  developed  and  the  evidences  of  systemic  infection  become 
manifest,  the  prognosis  is  worse  and  worse. 

Treatment. — The  curative  treatment  of  chronic  miliary  tuber- 
culosis is  embraced  in  two  principal  things — climate  and  feeding. 

The  selection  of  a  proper  climate  is  to  be  made  with  reference 
to  the  individual  rather  than  to  the  condition  of  the  lungs.  It 
should  be  a  climate  where  he  feels  well,  eats  well,  sleeps  well,  and 
gains  flesh  and  strength.  If  no  one  climate  answers  this  pur- 
pose, the  patient  should  travel  from  place  to  place.  The  climatic 
treatment  should  be  continued,  if  possible,  for  two  full  years,  and 
for  some  persons  it  is  necessary  that  they  should  pass  the  rest  of 
their  lives  in  a  favorable  climate. 

The  feeding  consists  in  enabling  the  patient  to  eat  and  digest 
considerable  quantities  of  wliolesome  food  and  of  fats.    To  do  tins 


MILIARY   TUBERCULOSIS.  lOI 

the  most  minute  attention  is  necessary  to  the  functions  of  the 
stomach,  the  liver,  and  the  intestines.  Great  care  should  be  taken 
to  avoid  the  use  of  all  medicines  which  interfere  with  the  patient's 
ability  to  eat  and  digest  food.  Wines  and  spirits  will  with  some 
persons  increase  the  appetite  and  the  nutrition,  with  other  per- 
sons they  interfere  with  digestion  and  do  harm.  Often  we  are 
much  lielped  by  the  use  of  the  stomach-tube.  Not  only  can  we 
in  this  way  cure  a  complicating  chronic  gastritis,  but  we  can  intro- 
duce into  the  stomach  much  larger  quantities  of  fluid  food  than 
the  patients  are  willing  to  swallow. 

It  may  also  be  necessary  to  alleviate  symptoms.  The  cough 
is  not  only  annoying,  but  it  often  interferes  witli  eating  and  sleep- 
ing. It  is,  therefore,  important  in  each  case  to  determine  the 
principal  cause  of  the  cough. 

It  may  be  due  to  a  catarrhal  inflammation  of  the  nose  and 
throat,  or  to  either  a  catarrhal  or  tubercular  inflammation  of  the 
larynx.  These  conditions  are  best  treated  by  local  applications 
made  with  the  spray  or  with  the  brush. 

It  may  be  due  to  the  pleuritic  adhesions.  If  this  is  the  case 
counter-irritation  by  blisters  or  iodine  may  be  of  service,  but 
some  of  these  pleuritic  coughs  can  only  be  controlled  by  opium. 

For  the  cough  which  is  due  to  the  bronchitis  and  to  the  cavi- 
ties a  great  many  remedies  have  been  employed.  In  selecting 
from  these  remedies  .it  is  well  to  prefer  those  which  do  not  dis- 
order the  stomach.  Creosote  seems  to  be  capable  of  exerting  a 
real  effect  on  the  bronchitis,  but,  unfortunately,  it  is  apt  to  dis- 
order the  stomach.  I  prefer  to  use  it  by  inhalation,  or  by  enema. 
For  inhalation  a  mixture  is  made  of  equal  parts  of  creosote, 
chloroform,  and  alcohol.  The  sponge  of  a  Robinson's  inhaler  is 
moistened  with  a  few  drops  of  this  mixture,  and  the  patient  wears 
the  inhaler  all  the  time  except  when  sleeping  or  eating.  An 
enema  is  easily  made  up  of  five  to  twenty  drops  of  creosote 
with  some  white  of  egg  and  a  little  water,  and  this  can  be  used 
once  a  day.  The  different  preparations  of  tar  and  of  turpentine, 
terebene  and  terpine  hydrate,  seem  to  be  of  service  in  some  cases. 
The  methodical  inhalation  of  compressed  air  is  highly  thought 
of  by  some  physicians.  All  sorts  of  combinations  of  opium, 
ipecac,  squills,  sanguinaria,  hydrocyanic  acid,  chloroform,  senega, 
etc.,  are  given  as  cough  mixtures.  The  mineral  acids,  nux  vom- 
ica or  strychnia  and  potassium  iodide  may  somewhat  control  the 
bronchitis. 


102  PHTHISIS. 

If  the  patients  are  anaemic  they  may  be  benefited  by  one  of 
the  preparations  of  iron. 

The  hemorrhages  from  the  bronchi  may  be  small  or  large, 
but  even  if  large  and  continued  for  several  days  they  are  very 
seldom  fatal.  They  do,  however,  weaken  the  patient  very  much, 
and  are  often  followed  by  an  extension  of  the  tubercular  pneu- 
monia. To  check  such  hemorrhages  it  is  customary  to  use  hypo- 
dermic injections  of  morphine  or  of  ergotine,  or  to  give  by  the 
mouth  five  grains  of  gallic  acid  every  two  hours,  twenty  drops  of 
fluid  extract  of  hydrastis  every  three  hours,  or  one  grain  of  ipecac 
every  hour. 

The  hemorrhages  which  come  from  eroded  vessels  in  the 
walls  of  cavities  cannot  be  controlled. 

The  fever  and  night-sweats  rnay  be  made  less  severe  by  the 
use  of  antifebrin  or  phenacetine  alone,  or  combined  with  arsenic 
or  quinine  ;  by  the  mineral  acids,  belladonna,  or  the  oxide  of 
zinc  ;  by  sponging  off  the  body  with  hot  water  at  night. 

For  the  diarrhoea  we  employ  a  restricted  diet,  and  a  number 
of  drugs.  The  drugs  most  frequently  employed  are  :  the  prepa- 
rations of  mercury,  ipecac,  iron,  arsenic,  camphor,  acetate  of 
lead,  bismuth,  castor-oil,  opium,  and  naphthalin.  These  drugs 
are  used  singly  or  combined  in  different  ways. 

Acute  Tubercular  Phthisis. 

Synonyms, — Acute  catarrhal  phthisis.     Acute  consumption. 

Definition. — An  acute  affection  of  the  lungs  characterized  by 
the  association  of  tubercular  inflammation  with  other  forms  of 
inflammation  —  either  exudative  or  productive,  or  both.  The 
name  is  an  arbitrary  one,  and  is  used  for  convenience  to  group 
together  a  set  of  clinical  cases. 

Etiology. — An  attack  of  acute  phthisis  may  follow  some  pre- 
vious tubercular  inflammation  of  the  lung,  or  it  may  be  a  prim- 
ary inflammation.  A  person  who  has  the  tubercular  predispo- 
sition, when  exposed  to  the  ordinary  causes  of  inflammation  of 
the  lung,  and  at  the  same  time  infected  with  tubercle  bacilli,  in- 
stead of  having  a  simple  exudative  or  productive  pneumonia, 
has  an  inflammation  of  the  lung,  partly  tubercular,  partly  exuda- 
tive, partly  productive. 

Morbid  Anatomy. — The  inflammation  of  the  lungs  may  follow 
one  of  several  types,  all  of  which  have  much  the  same  clinical  his- 
tory, but  vary  in  their  physical  signs. 


PHTHISIS.  103 

1.  One  or  more  lobes  are  completely  consolidated.  The  con- 
solidation is  effected  by  the  filling  of  the  air-spaces  and  small 
bronchi  with  epithelium,  fibrin,  and  pus.  Scattered  through  the 
consolidation  are  miliary  tubercles.  The  pleura  is  coated  with 
fibrin. 

2.  Tliere  is  a  general  catarrhal  bronchitis  and  a  tubercular  in- 
flammation of  the  walls  of  some  of  the  bronchi  and  of  small  zones 
of  air-spaces  immediately  surrounding  them.  The  lung  is  not 
consolidated,  but  a  section  of  it  appears  to  be  studded  with  little 
nodules,  each  nodule  is  the  section  of  a  bronchus  with  thickened 
wall  and  surrounded  by  a  zone  of  filled  air-spaces. 

3.  There  is  a  general  catarrhal  bronchitis,  a  tubercular  inflam- 
mation of  the  walls  of  some  of  the  bronchi  and  of  the  air-spaces 
which  surround  them,  but  in  addition  there  are  small  or  large 
areas  of  diffuse  consolidation  due  to  the  filling  of  air-spaces  with 
epithelium,  pus,  and  fibrin.  The  pulmonary  pleura  is  often 
coated  with  fibrin. 

4.  Besides  the  tubercular  broncho-pneumonia,  the  diffuse  con- 
solidation, and  the  pleurisy,  small  or  large  portions  of  the  in- 
flamed lung  die.  These  dead  portions  of  lung  first  pass  into  the 
condition  of  coagulation  necrosis,  and  then  undergo  cheesy  de- 
generation. They  may  remain  in  the  condition  of  cheesy  de- 
generation for  a  long  time  and  become  surrounded  by  zones  of 
tubercle  tissue  or  of  round-celled  tissue  ;  or  they  often  break  down 
and  form  ragged  cavities  which  communicate  with  the  bronchi. 

5.  In  addition  to  the  lesions  already  mentioned,  the  walls  of 
the  bronchi  are  so  changed  by  the  tubercular  inflammation  that 
cylindrical  or  sacculated  bronchiectasiae  are  formed. 

Symptoms. — The  invasion  may  be  acute  or  subacute, 
I.  The  acute  cases.  The  patients  are  suddenly  attacked  with 
chills,  fever,  pain  in  the  side,  cough  with  mucous  expectoration, 
and  marked  prostration.  The  appearance  of  the  patient  is  like 
that  of  a  person  attacked  with  lobar  or  broncho-pneumonia,  and 
we  are  often  in  doubt  at  first  as  to  the  true  nature  of  the  disease. 
One  symptom  of  the  invasion,  however,  is  not  often  seen  except 
with  phthisis  and  that  is  the  bleeding  from  the  bronchi.  For  a 
day,  or  for  several  days,  many  of  the  patients  cough  up  very  con- 
siderable quantities  of  blood.  Within  a  few  days  we  begin  to  get 
the  physical  signs,  which  will  be  found  to  vary  according  to  the 
anatomical  condition  of  the  lung.  If  there  is  complete  consoli- 
dation of  one  or  more  lobes  with  fibrin  on  the  pleura  we  get  dul- 


104  PHTHISIS. 

ness  oil  percussion,  bronchial  voice  and  breathing,  and  subcrepi- 
tant  and  crepitant  rales.  If  there  is  only  broncho-pneumonia 
without  consolidation,  we  get  sibilant  and  sonorous  breathing  and 
coarse  and  subcrepitant  rales.  If  there  is  broncho-pneumonia 
with  areas  of  diffuse  consolidation,  we  get  sibilant  and  sonorous 
breathing,  coarse  and  subcrepitant  rales,  and  small  areas  over 
which  there  are  dulness  on  percussion,  increased  voice,  and 
a  crepitant  rale  are  found.  The  patients  continue  seriously  ill 
and  with  high  temperatures  for  one  or  two  weeks.  Then  there  is 
a  partial  subsidence  of  the  symptoms.  After  this  the  patients 
may  : 

{a)  Continue  to  get  worse.  The  fever  continues,  the  cough  is 
very  troublesome  and  accompanied  with  muco-purulent  expec- 
toration, there  is  rapid  loss  of  flesh  and  strength,  the  patients  pass 
into  the  typhoid  state  with  alternating  delirium  and  stupor.  The 
physical  signs  which  existed  earlier  in  the  disease  continue  and 
there  are  added  the  coarse  and  gurgling  rales  which  accompany 
the  dilatation  of  the  bronchi  and  the  softening  of  the  dead  areas 
of  consolidation.  These  patients  die  at  the  end  of  a  few  weeks 
or  months. 

(d)  Improve  very  considerably.  The  temperature  falls,  the 
expectoration  diminishes,  the  cough  is  less  frequent,  the  appetite 
returns.  The  patients  gain  flesh  and  strength,  they  are  able  to 
leave  the  bed,  and  later  the  house,  but  yet  they  are  not  well.  A 
considerable  portion  of  the  lung  remains  diseased  and  the  patients 
go  on  to  the  condition  of  chronic  phthisis. 

(c)  Recover.  Of  the  lesions  of  acute  phthisis,  the  tubercular 
changes,  the  death  of  portions  of  lung,  and  the  dilatation  of  the 
bronchi  are  necessarily  permanent.  On  the  other  hand,  the 
catarrhal  bronchitis  may  subside,  the  epithelium,  pus,  and  fibrin 
within  the  air-spaces  may  degenerate  and  be  absorbed.  It  is 
possible,  therefore,  for  the  patients  who  have  only  catarrhal 
bronchitis,  exudative  pneumonia,  and  comparatively  little  tuber- 
cular pneumonia  to  recover.  We  see  this  in  two  sets  of  cases. 
First,  the  patients  who  have  consolidation  of  an  entire  lobe  due 
to  the  filling  of  the  air-spaces  with  epithelium,  pus,  and  fibrin, 
and  to  the  presence  of  miliary  tubercles.  The  epithelium,  pus, 
and  fibrin  can  be  absorbed,  the  tubercles  are  converted  into 
fibrous  tissue,  and  the  patients  get  well  with  a  lung  which  is  nor- 
mal except  for  the  presence  of  fibrous  nodules.  Second,  the 
patients  who   have   tubercular   broncho-pneumonia  without  de- 


PHTHISIS.  105 

struction  or  dilatation  of  the  bronclii,  and  without  areas  of  diffuse 
consolidation.  The  patients  can  get  well  with  lungs  which  are 
normal  except  for  the  presence  of  a  number  of  peri-bronchitic 
fibrous  nodules. 

2.  The  subacute  cases.  The  extent  of  lung  at  first  involved  is 
small,  but  gradually  increases  in  size.  The  patients  usually  have 
cough  with  mucous  or  muco-purulent  sputa  which  contain 
bacilli,  but  sometimes  there  is  very  little  either  of  cough  or  of 
expectoration,  and  that  even  while  cavities  are  being  formed. 
The  difficulty  in  breathing  increases  with  the  extent  of  lung  in- 
volved, pain  over  the  chest  is  present  in  some  cases,  absent  in 
others. 

There  is  regularly  a  rise  of  temperature  in  the  afternoon  with 
sweating  at  night,  and  the  temperature  is  higher  and  more  con- 
tinuous after  cavities  with  suppurating  walls  are  formed.  But 
we  have  to  become  accustomed  to  very  great  discrepancies  be- 
tween the  lung  lesion  and  the  height  of  the  temperature,  and 
even  to  find  no  fever  with  an  advancing  consolidation  of  the 
lung. 

There  may  be  bleeding  from  the  bronchi  or  from  eroded  ves- 
sels in  the  walls  of  cavities.  A  large  hemorrhage  from  the  bronchi 
is  apt  to  precede  the  inflammation  of  a  fresh  portion  of  the  lung. 
The  patients,  as  a  rule,  have  no  appetite  and  gradually  lose  flesh 
and  strength.  But  in  some  persons  the  changes  in  the  lung  for 
some  time  produce  very  little  effect  on  the  general  health.  And 
it  is  sometimes  very  curious,  and  of  importance  in  judging  of 
treatment,  to  see  patients  eating  well  and  gaining  flesh  with  con- 
solidation of  an  entire  lung  and  without  any  real  improvement 
in  their  tubercular  pneumonia. 

The  physical  signs  are  those  of  the  pleurisy,  the  consolida- 
tion, the  bronchitis,  and  the  cavities. 

The  patients  are  for  the  most  part  not  sick  in  bed,  and  the 
disease  progresses  either  continuously  or  in  attacks. 

Some  of  the  patients  go  on  to  have  chronic  phthisis.  Some 
of  them  recover,  but  with  lungs  more  or  less  permanently  dam- 
aged. Often  these  patients  can  only  escape  fresh  attacks  by 
remaining  permanently  in  a  favorable  climate. 

The  Prognosis  of  acute  phthisis  is  unfavorable.  Complete  re- 
coveries are  rare,  but  the  number  of  patients  who  go  on  living 
with  damaged  lungs  for  many  years  is  considerable. 

Treatment. — While  the  inflammation  of  the  lungs  is  active  the 


I06  PHTHISIS. 

patients  are  to  be  kept  in  bed,  on  a  fluid  diet,  tlie  liaemoptysis 
controlled  by  ergot,  hydrastin  or  ipecac,  the  patients  made  more 
comfortable  by  opium  or  the  bromides. 

As  the  acuteness  of  the  inflammation  subsides,  the  patients 
return  to  solid  food,  they  get  out  of  bed,  and  tlie  question  of  a 
suitable  climate  for  them  has  to  be  determined. 

In  some  cases  it  is  evident  that  the  changes  in  the  lungs  are 
so  extensive  and  profound  that  no  improvement  can  be  ex- 
pected ;  these  patients  are  best  kept  at  home. 

In  some  cases  the  extent  of  lung  involved  is  comparatively 
small,  so  that  we  may  hope  for  complete  or  incomplete  recovery. 
The  proper  climate  for  these  patients  is  a  dr\',  inland  one,  where 
they  are  not  likely  to  have  fresh  attacks  of  inflammation  of  tlie 
lung.  Whether  this  climate  should  be  a  warm  or  a  cold  one, 
must  be  determined  by  the  character  of  the  individual.  In  the 
cases  of  tubercular  broncho-pneumonia  without  consolidation  a 
cold,  dry,  inland  climate  seems  to  be  the  best. 

The  symptomatic  treatment  is  the  same  as  tliat  used  in  the 
cases  of  acute  miliary  tuberculosis. 

Chronic  Tubercular  Phthisis. 

Definition. — A  chronic  affection  of  the  lungs  characterized  by 
tubercular  inflammation  associated  with  productive  and  exu- 
dative inflammation. 

Etiology. — Clironic  phthisis  regularly  succeeds  acute  or  sub- 
acute phthisis,  but  it  may  also  follow  acute  or  chronic  miliary 
tuberculosis  of  the  lungs,  or  a  tubercular  inflammation  of  some 
other  part  of  the  body. 

Morbid  Anato77iy. — The  changes  in  the  lungs  are  of  the  same 
nature  as  those  found  in  acute  phthisis,  but  modified  by  the  long 
duration  of  the  inflammation.  The  pleura  is  coated  with  suc- 
cessive layers  of  fibrin,  or  thickened  by  the  growth  of  new  con- 
nective tissue,  or  covered  with  adhesions.  More  or  less  of  the 
lung  is  consolidated.  This  consolidation  is  effected  partly  by 
the  filling  of  the  cavities  of  the  air-spaces  with  inflammatory 
products,  partly  by  a  growth  of  new  tissue  in  the  walls  of  the 
air-spaces  and  between  them. 

When  the  hepatization  is  effected  only  by  changes  within  the 
cavities  of  the  air-spaces,  the  affected  portions  of  lung  are  solid, 
increased  in  size  of  red,  gray,  white,  or  yellow  color.     When  the 


PHTHISIS.  107 

hepatization  is  due  to  interstitial  inflammation  tlie  affected  por- 
tion of  lung  is  dense,  but  may  still  be  partly  aerated  ;  it  is  dimin- 
ished in  size  and  looks  like  fibrous  tissue  or  granulation  tissue,  it 
is  often  changed  in  color  by  the  deposition  of  black  pigment. 
The  combination  of  intra-alveolar  and  interstitial  pneumonia 
with  dilatation  of  the  bronchi  and  the  formation  of  cavities  gives 
a  great  variety  of  pictures. 

We  find  some  of  the  air-spaces  filled  vvitli  large  epithelial 
cells  either  well  formed  or  fatty  ;  some  witli  an  amorphous 
granular  matter,  or  a  peculiar  translucent  coagulated  sub- 
stance ;  some  with  fibrin,  pus,  and  epithelium  either  fresh  or  in 
the  condition  of  cheesy  degeneration  ;  some  with  new  connective 
tissue.  The  walls  of  these  air-spaces  remain  unchanged,  or  they 
are  compressed  and  the  blood-vessels  obliterated,  or  they  are 
thickened. 

The  interstitial  inflammation  affects  the  walls  of  the  air- 
spaces, the  bronchi,  the  blood-vessels  and  the  septa  between  the 
lobules.  It  results  in  the  production  of  new  connective  tissue, 
of  round-celled  tissue  and  of  tubercle  tissue,  either  separately 
or  together.  By  this  growth  the  air-spaces  are  compressed,  de- 
formed, and  obliterated  in  a  variety  of  ways. 

The  walls  of  some  of  the  bronchi  are  infiltrated  with  round 
cells  or  with  tubercle  tissue.  This  infiltration  is  not  symmetrical, 
but  affects  a  bronchus  in  some  particular  portion  of  its  length, 
and  in  this  portion  some  parts  of  the  circumference  of  the  bron- 
chus are  affected  more  than  others.  As  a  result  of  this  irregu- 
lar infiltration  the  wall  of  the  bronchus  yields  here  and  there,  and 
small  sacculated  dilatations  are  formed.  In  some  cases,  espe- 
cially in  chronic  miliary  tuberculosis,  the  cavities  thus  formed 
simply  became  larger  and  larger,  compressing  the  surrounding 
lung.  More  frequently,  however,  the  process  extends  from  the 
wall  of  the  bronchus  to  the  surrounding  air-vesicle,  so  that  the 
bronchus  is  surrounded  with  tubercle  tissue,  round-celled  tissue, 
and  air-vesicles  filled  with  inflammatory  products.  Then  necro- 
sis sets  in,  with  softening  of  the  walls  of  the  bronchus  and  of  the 
surrounding  inflamed  lung.  So  cavities  are  formed  partly  by  de- 
struction of  tissue,  partly  by  dilatation  of  bronchi  of  which  the 
walls  are  either  necrotic  or  suppurating. 

Some  of  the  cavities  in  chronic  phthisis  seem  to  be  formed 
simply  by  the  softening  of  areas  of  coagulation  necrosis,  but  the 
larger  number  are  bronchiectasise  such  as  have  just  been  described. 


I08  PHTHISIS. 

The  cavities  which  are  formed  by  dilatation  without  necrosis 
of  their  walls  may  be  developed  with  hardly  any  cough  or  expec- 
toration. As  we  examine  the  patients  from  time  to  time,  the 
change  in  the  percussion  and  the  breathing  show  the  increasing 
size  of  a  cavity  which  remains  nearly  dry  and  empty. 

The  cavities  formed  botli  by  dilatation  and  necrosis,  on  the 
contrary,  are  regularly  accompanied  by  an  harassing  cough  and 
profuse  expectoration.  They  contain  pus,  mucus,  fragments  of 
dead  tissue,  and  great  numbers  of  tubercle  bacilli.  Their  walls 
are  ragged  and  irregular,  partly  necrotic,  partly  suppurating. 
In  this  active  condition  the  cavities  may  remain  up  to  the  time  of 
the  patient's  death.  Or,  instead  of  this,  the  active  processes  may 
subside,  the  production  of  pus  and  the  death  of  tissue  cease,  the 
cavity  become  dry  and  its  walls  changed  into  fibrous  tissue. 
The  natural  tendency  of  all  these  cavities  is  to  increase  in  size 
and  open  into  each  other. 

Miliary  tubercles  are  scattered  through  the  inflamed  lung  in 
varying  numbers. 

The  "tubercle  bacilli  are  found  principally  in  the  walls  of  the 
cavities  and  in  the  inflammatory  products  which  have  undergone 
cheesy  degeneration. 

Symptoms. — The  cough  depends  principally  upon  the  bronchi- 
tis and  the  morbid  processes  going  on  in  the  walls  of  cavities. 
The  expectoration  consists  of  mucus,  pus,  and  fragments  of  dead 
lung  tissue,  with  many  tubercle  bacilli.  But  in  patients  with 
consolidation  of  the  lung  without  bronchitis,  and  with  cavities  of 
which  the  walls  are  comparatively  healthy,  the  cough  and  expec- 
toration amount  to  very  little.  Generally  speaking,  however, 
the  quantity  of  the  sputa  and  the  number  of  the  bacilli  are  a  fair 
test  of  the  activity  of  the  morbid  process. 

Haemoptysis  occurs  in  a  large  proportion  of  the  cases,  and  at 
any  time  in  the  course  of  the  disease.  After  some  of  these  bleed- 
ings the  patients  feel  more  comfortable,  but  after  others  there  is 
a  rapid  extension  of  the  disease.  Hemorrhages  from  eroded  ves- 
sels in  the  walls  of  cavities  are  very  dangerous. 

In  some  of  the  patients  the  pleurisy  from  time  to  time  gives 
pain.  In  others  there  is  a  considerable  exudation  of  serum  in 
one  of  the  pleural  cavities,  which  increases  the  difficulty  in 
breathing.  The  softening  of  a  dead  portion  of  lung  or  the  rupt- 
ure of  the  wall  of  a  cavity  just  beneath  the  pleura  may  cause 
perforation,  pneumothorax,  and  then  either  a  pleurisy  with  effu- 


PHTHISIS.  109 

sion,  or  an  empyema.  At  the  time  of  the  perforation  the  patients 
feel  as  if  something  had  given  way,  and  at  once  suffer  from  the 
most  urgent  dyspncea.  The  heart's  action  becomes  rapid  and 
feeble,  and  the  veins  throughout  the  body  congested.  Tlie  char- 
acteristic physical  signs  are  soon  evident.  Such  a  perforation 
usually  proves  fatal  within  a  few  days  or  weeks. 

The  dyspnoea  on  exertion  increases  with  the  extension  of  the 
disease  and  the  consequent  diminution  in  the  extent  of  lung 
available  for  breathing. 

Tubercular  laryngitis  occurs  later  in  the  disease  with  chronic 
phthisis  than  with  chronic  miliary  tuberculosis.  It  gives  rise  to 
cough,  hoarseness,  and  pain. 

The  fever  and  the  sweating  at  night  seem  to  be  related  to  the 
severity  of  the  bronchitis,  and  of  the  necrosis  and  suppuration 
of  the  cavities.  The  temperature  rises  and  falls  according  to  the 
activity  of  these  conditions.  The  consolidation  of  the  lung  alone 
can  extend  with  little  or  no  fever. 

The  functions  of  the  stomach  and  liver  are  sooner  or  later 
affected,  either  with  or  without  chronic  catarrhal  gastritis  and 
fatty  infiltration  of  the  liver.  Loss  of  appetite,  repugnance  to 
food,  nausea.  Vomiting,  and  gastric  pain  may  seriously  annoy  the 
patient. 

Toward  the  close  of  the  disease  a  severe  diarrhoea  often  sets 
in,  and  the  patients  lose  flesh  and  strength  very  rapidly.  In 
these  patients  after  death  we  may  find  tubercular  ulcers  of  the 
small  intestine  or  only  a  catarrhal  colitis.  It  may  also  happen 
that  extensive  tubercular  ulcers  of  the  small  intestine  exist  with- 
out any  diarrhoea  at  all. 

Tubercular  meningitis,  or  peritonitis,  or  nephritis  may  occur 
as  complicating  inflammations. 

Chronic  degeneration  of  the  kidney,  or  chronic  nephritis  with 
or  without  exudation,  are  often  developed  after  the  phthisis  has 
lasted  for  some  time. 

In  women  menstruation  is  either  irregular,  or  stops  alto- 
gether. 

The  physical  signs  with  only  a  small  area  of  lung  consolidated 
are  :  dulness  on  percussion,  broncho-vesicular  or  feeble  breath- 
ing, increased  vocal  resonance,  increased  bronchial  whisper,  and 
in  addition,  subcrepitant  rales  and  friction  sounds.  As  more  of 
the  lung  is  consolidated  the  dulness  on  percussion  becomes  more 
marked,  the  voice   and   breathing  approach  more   nearly  to  the 


no  PHTHISIS. 

bronchial  character,  and  an  increasing  broncliitis  gives  coarse 
and  subcrepitant  rales.  After  cavities  have  been  formed  the 
percussion  sound  changes  to  flatness,  tympanitic  resonance,  or 
the  cracked-pot  sound.  The  breathing  and  voice  remain  of  bron 
chial  quality,  or  become  cavernous.  There  may  be  gurgling 
rales. 

Tlie  patients  regularly  lose  flesh  and  strength  in  proportion 
to  the  extent  of  lung  diseased.  But  it  is  not  rare  to  see  persons 
who  are  well  nourished  and  comparatively  strong  with  extensive 
changes  in  the  lungs. 

If  we  compare  chronic  miliary  tuberculosis  with  chronic 
phthisis,  we  may  say  that  in  the  former  there  are  but  few  tuber- 
cle bacilli  in  the  sputa  or  in  the  lungs,  but  little  necrosis  or  sup- 
puration, and  less  consolidation  of  the  lung,  but  a  loss  of  health 
and  nutrition  much  greater  than  would  be  expected  from  the 
extent  of  the  pulmonary  lesion. 

In  chronic  phthisis,  on  the  other  hand,  the  number  of  tuber- 
cle bacilli  in  the  sputa  and  in  the  lungs  is  large,  necrosis  and 
suppuration  are  regularly  present,  the  patients  seem  to  suffer 
rather  from  septic  than  from  tubercular  infection,  the  severity  of 
the  symptoms  is  usually  in  direct  relation  with  the  extent  of  lung 
inflamed. 

Prognosis. — It  is  possible  for  the  inflammatory  and  necrotic 
processes  which  belong  to  chronic  phthisis  at  any  time  to  cease. 
When  this  happens,  all  symptoms  of  pulmonary  disease  may  also 
cease  and  the  patients  are  apparently  cured.  The  portions  of 
lung,  however,  which  have  been  destroyed  or  converted  into 
fibrous  tissue  are  never  replaced  by  lung  tissue,  so  that  the  in- 
jury inflicted  on  the  lungs  is  a  permanent  one.  The  fibrous  tis- 
sue and  cheesy  masses  left  behind  after  the  subsidence  of  active 
changes  are  liable  to  act  as  foci,  from  which  fresh  attacks  of 
inflammation  and  fresh  infection  may  proceed.  The  prognosis 
is,  therefore,  unfavorable,  although  life  may  be  prolonged  in 
comparative  comfort  for  many  years. 

Treatment. — Cases  of  chronic  phthisis  are  to  be  managed  in 
the  same  way  as  are  the  cases  of  chronic  miliary  tuberculosis. 

In  a  work  of  this  kind  it  is  not  necessary  to  describe  the  plans 
of  treatment  by  such  agents  as  sulphuretted  hydrogen,  tuber- 
culin, chloride  of  gold,  etc.  None  of  them  have  as  yet  proved 
satisfactory. 


SYPHILITIC    PNEUMONIA.  Ill 


Syphilitic  Pneumomia. 


In  children  wlio  have  inherited  syphilis,  a  number  of  inflam- 
mations of  different  parts  of  the  body  are  liable  to  be  developed 
soon  after  birth.  The  lungs  are  not  exempt.  They  may  be 
studded  with  gummy  tumors  of  different  sizes,  or  they  may  be 
the  seat  of  interstitial,  or  of  intra-alveolar  pneumonia. 

The  interstitial  pneumonia  may  cause  the  consolidation  of  one 
or  more  lobes.  The  section  of  such  a  consolidated  lobe  is  smooth 
and  of  grayish  or  white  color.  The  consolidation  is  effected  by  a 
growth  of  new  tissue  in  the  walls  of  the  air-spaces,  the  bronclii, 
and  the  blood-vessels,  together  with  the  filling  of  some  of  the  air- 
spaces with  epithelium. 

The  intra-alveolar  pneumonia  also  produces  a  whitish  hepa- 
tization of  considerable  portions  of  the  lung.  But  the  consolida- 
tion is  effected  entirely  by  the  filling  of  the  air-spaces  with  fatty 
epithelium. 

The  clinical  symptoms  in  these  children  are  obscure.  They 
often  have  other  syphilitic  lesions  besides  those  in  the  lungs,  and 
become  weaker  and  more  emaciated  from  day  to  dav,  without  any 
pulmonary  symptoms  except  the  physical  signs  of  the  consoli- 
dation. 

In  adults,  syphilitic  inflammations  of  the  lung  are  rare.  The 
best  collection  of  cases  that  I  have  seen  is  that  given  by  Hiller  in 
the  Charite  Annalen  for  1884.  He  gives  58  cases  of  unmistakable 
syphilitic  pneumonia. 

Morbid  Anatomy. — The  inflammation  is  of  productive  charac- 
ter with  the  formation  of  round-celled  tissue,  of  gummv  tumors, 
and  of  new  connective  tissue.  There  may  also  be  some  exudation 
into  the  air-spaces  and  a  formation  of  epithelial  cells  in  the  air- 
spaces. The  new  tissue  is  formed  in  the  walls  of  the  bronchi,  the 
walls'of  the  air-spaces,  the  walls  of  the  blood-vessels,  the  septa 
between  the  lobules  and  the  pleura.  The  new  tissue  is  of  low 
vitality  and  may  become  necrotic.  There  results  from  such  an 
inflammation,  therefore  :  stenosis,  ulceration  or  dilatation  of  the 
bronchi,  consolidation  of  parts  of  the  lung,  obliteration  of  the 
blood-vessels,  lobulation  of  the  lung,  and  thickening  of  the 
pleura. 

The  gross  appearance  of  the  lungs  will  accordingly  vary  in 
different  cases. 


112  SYPHILITIC   PNEUMONIA. 

1.  There  is  an  interstitial  inflammation  beginning  at  the  root 
of  the  lung  around  the  large  bronchi  and  blood-vessels.  This 
causes  stenosis  of  the  bronchi,  consolidation  of  the  lung,  or 
masses  of  fibrous  tissue  along  the  lines  of  the  bronchi.  The 
cases  vary  as  to  whether  the  stenosis  of  the  bronchi  or  the  con- 
solidation of  the  lung  is  the  principal  feature. 

2.  The  inflammation  follows  the  type  of  a  broncho-pneu- 
monia, with  thickening  of  the  walls  of  the  bronchi  and  small 
zones  of  peri-bronchitic  pneumonia. 

3.  There  are  large  or  small  irregular  masses,  or  bands,  of 
dense  fibrous  tissue  in  any  part  of  the  lung.  These  replace  the 
lung  tissue,  and  in  them  may  be  cavities  formed  by  the  dilatation 
of  the  bronchi. 

4.  With  the  interstitial  pneumonia  there  may  be  associated 
the  formation  of  gummy  tumors,  or  an  obliterating  endarteritis 
with  areas  of  necrosis. 

5.  With  more  or  less  interstitial  pneumonia  at  the  roots  of 
the  lungs  there  is  a  syphilitic  inflammation  of  the  walls  of  the 
large  bronchi,  the  trachea,  and  the  larynx.  These  walls  are 
thickened  in  some  places,  ulcerated  in  others,  so  that  in  some 
places  there  is  stenosis,  in  others  dilatation. 

6.  We  also  occasionally  meet  with  pneumonia  of  the  anatom- 
ical type  of  ordinary  lobar  or  broncho-pneumonia.  But  the 
clinical  history  although  acute  is  irregular,  and  it  is  probable, 
although  not  at  all  certain,  that  they  are  caused  or  modified  by 
the  syphilitic  poison. 

Symptoms. — Syphilitic  pneumonia  is  one  of  the  later  manifes- 
tations of  syphilis,  in  most  of  the  cases  coming  on  several  years 
after  the  initial  lesion.  A  great  many  of  the  patients  have  other 
syphilitic  lesions,  a  fact  of  much  assistance  in  making  a  diag- 
nosis which  is  always  difficult. 

Of  the  pulmonary  symptoms  perhaps  the  most  constant  is 
dyspnoea.  This  is  like  any  dyspnoea  due  to  narrowing  of  the 
trachea  or  large  bronchi.  First  a  dyspnoea  on  exertion,  then  a 
constant  dyspnoea  made  worse  by  the  least  bodily  or  mental  ex- 
ertion, and  becoming  more  and  more  distressing  up  to  the  time 
of  the  patient's  death. 

Cough  is  present  at  some  time  in  most  of  the  cases,  a  dry 
cough,  a  laryngeal  cough,  or  a  cough  with  mucus  or  muco-puru- 
lent  expectoration.  Small  haemoptyses  occur  from  time  to  time 
in  some  cases. 


SYPHILITIC   PNEUMONIA.  II  3 

Pain  referred  to  some  part  of  the  chest  is  present  in  some 
cases,  absent  in  others. 

A  febrile  movement  seems  to  be  the  exception  rather  than 
the  rule. 

If  a  syphilitic  laryngitis  exists  the  symptoms  belonging  to 
this  will  be  added  to  those  of  the  pneumonia. 

The  physical  signs  vary  with  the  exact  condition  of  the  lungs 
and  are  often  obscure.  They  depend  upon  the  pleurisy,  the 
bronchitis,  the  stenosis  or  dilatation  of  the  bronchi,  and  the  con- 
solidation of  the  lung. 

So  in  the  different  cases  we  may  get  tubular  breathing  over 
one  or  both  lungs,  absence  of  breathing  over  one  lung  or  part 
of  a  lung,  subcrepitant,  coarse,  or  gurgling  rales,  usually  local- 
ized, dulness  on  percussion,  and  increase  in  vocal  resonance  ac- 
cording to  the  extent  of  the  consolidation. 

The  fact  that  the  inflammation  involves  the  roots  of  the  lungs 
rather  than  their  apices  causes  the  physical  signs  to  be  heard 
largely  over  the  central  portions  of  the  lungs,  while  in  tubercular 
inflammations  of  the  lungs  it  is  over  the  upper  lobes  that  the 
physical  signs  are  usually  heard. 

The  symptoms  continue  for  weeks  or  months,  the  patients 
gradually  lose  flesh  and  strength,  and  finally  die  from  the  inter- 
ference with  breathing  or  worn  out  with  the  disease. 

The  Diagnosis  is  apt  to  be  difficult.  The  symptoms  resemble 
those  of  chronic  tuberculosis,  of  aneurism  of  the  aorta,  of  intra- 
thoracic tumors,  and  of  actinomycosis  of  the  lung.  We  are  very 
dependent  upon  the  history  of  the  patient  and  the  presence  of 
other  syphilitic  lesions. 

Treatment — -It  is  natural  in  these  patients  to  adopt  an  energetic 
treatment  with  mercury  and  the  iodide  of  potash,  although  the 
rule  seems  to  be  that  the  disease  is  fatal. 

Gangrene  of  the  Lung. 

Definition. — Death  accompanied  by  putrefaction  of  a  portion 
of  the  lung. 

Etiology. — Whenever  the  vitality  of  a  portion  of  the  lung  is  im- 
paired and  at  the  same  time  the  bacteria  of  putrefaction  are  pres- 
.ent,  there  may  be  gangrene.  It  is  found,  therefore,  with  lobar 
pneumonia,  haemorrhagic  infarctions,  compression  or  embolism 
of  the  pulmonary  or  bronchial  vessels,  wounds  of  the  lung^  con- 


114  GANGRENE   OF   THE   LUNG. 

tusions  of  tlie  chest,  cavities  in  the  lung,  foreign  bodies  in  the 
bronchi,  cancer  of  the  oesophagus,  and  in  persons  whose  health  has 
been  enfeebled  by  disease  or  privation.  But  it  also  occurs  without 
discoverable  cause  in  persons  who  have  been  in  good  health. 

Morbid  Anatomy. — Gangrene  of  the  lung  is  either  circum- 
scribed or  diffuse. 

Circumscribed  gangrene  occurs  in  the  form  of  one  or  more 
foci  of  small  size  where  tlie  lung  is  of  blackish  or  greenish  color, 
soft,  or  broken  down  into  ragged  cavities.  These  foci  have  a 
most  offensive  odor.  Tlie  lung  around  them  is  inflamed  and  the 
air-spaces  contain  epithelium,  fibrin,  and  pus.  Such  gangrenous 
foci  when  once  formed  may  increase  in  size  ;  as  they  do  so  the 
adjoining  veins  may  become  filled  with  infectious  thrombi,  or 
eroded.  From  tlie  thrombi  infectious  emboli  can  be  carried  into 
the  circulation  and  set  up  inflammatory  foci  in  different  parts  of 
the  body.  From  the  eroded  vessels  there  are  considerable  haem- 
orrhages. If  the  spot  of  gangrene  is  near  the  pleura  it  may  set 
up  either  a  simple  or  a  gangrenous  pleurisy.  Or  the  pulmonary 
pleura  may  be  perforated  and  pyopneumothorax  result.  In- 
tense bronchitis,  either  catarrhal  or  croupous,  may  be  excited  by 
the  irritation  of  the  gangrenous  matter.  If  the  patients  recover 
the  gangrenous  portion  of  lung  is  entirely  removed,  a  cavity  is 
formed  of  which  the  walls  are  changed  into  connective  tissue. 
Such  a  cavity  may  remain  for  a  long  time,  or  it  may  become  con- 
tracted. 

Diffuse  gangrene  may  be  secondary  to  the  circumscribed  form, 
or  it  may  be  diffuse  from  the  first.  The  greater  portion  of  a  lobe, 
a  whole  lobe,  or  even  a  whole  lung,  may  be  involved.  The  por- 
tion of  lung  involved  is  changed  into  a  soft,  foul-smelling,  black- 
ish or  greenish  mass. 

Symptoms. — The  patients  have  a  cough  with  more  or  less  fetid 
expectoration  and  a  fetid  breath.  There  is  much  variety  as  to  the 
quantity  of  the  expectoration,  it  may  be  scanty  or  abundant. 
When  it  is  abundant  and  is  allowed  to  stand  for  a  time  in  a  glass 
dish  it  separates  into  three  layers:  The  upper,  frothy,  opaque, 
and  of  a  dirty  gray  or  yellowish  color;  the  middle,  clear  and 
watery  ;  the  lower,  greenisli  and  purulent,  or  mixed  witli  blood. 
It  consists  of  serum,  mucus,  pus,  and  shreds  of  lung  tissue. 
There  may  be,  however,  only  a  very  fetid  breath  without  any  ex- 
pectoration. If  the  pulmonary  vessels  are  eroded  large  quantities 
of  blood  are  coughed  up. 


ASTHMA.  115 

The  patients  have  an  irregular  fever,  they  lose  flesh  and 
strength  and  pass  into  the  septic  condition.  But  some  of  the  pa- 
tients, who  apparently  have  gangrene  of  the  lung  and  recover, 
are  not  at  any  time  so  sick  as  one  would  expect. 

The  physical  signs  are  sometimes  obscure,  sometimes  well 
marked.  They  are  most  commonly  found  over  the  middle  of  the 
chest  behind.  At  this  point  we  mwy  get  dulness  or  flatness  on 
percussion  ;  absence  of  breathing,  bronchial  breathing,  or  cavern- 
ous breathing;  exaggerated  or  bronchial  voice,  and  coarse  rales. 

If  the  pleura  is  inflamed  or  perforated,  producing  pneumo- 
thorax, the  symptoms  belonging  to  these  conditions  are  added. 

The  diagnosis  is  often  difficult.  It  may  be  evident  that  the 
patient  has  a  serious  disease  and  yet  impossible  for  some  time  to 
determine  its  character.  Even  when  it  is  certain  that  there  is  a 
pulmonary  lesion  we  cannot  always  tell  whether  this  is  gangrene, 
abscess,  or  fetid  bronchitis. 

The  Prognosis  is  always  serious,  but  recovery  is  by  no  means 
impossible. 

Treatment. — Besides  the  employment  of  such  measures  as  add 
to  the  comfort  of  the  patients  and  contribute  to  their  nutrition, 
it  is  customary  to  give  creosote  or  carbolic  acid  either  by  inha- 
lation or  by  the  mouth.  Perhaps  the  simplest  plan  is  to  use  a 
Robinson's  inhaler  moistened  with  equal  parts  of  creosote,  alco- 
hol, and  chloroform. 

In  a  moderate  number  of  cases  gangrenous  cavities  in  the 
lungs  have  been  opened  and  drained. 

Asthma. 

Definition. — An  affection  characterized  by  paroxysmal  dysp- 
noea, recurring  at  intervals,  generally  in  the  night,  the  dyspnoea 
due  to  a  contraction  of  the  bronchi. 

The  same  name  of  asthma  is  also  frequently  employed  to 
designate  the  paroxysmal  dvspnoea  caused  by  disease  of  the  heart, 
and  by  contraction  of  the  arteries. 

Etiology. —  Bronchial  asthma  occurs  most  frequently  in  per- 
sons who  have  pulmonary  emphysema,  but  it  is  by  no  means  rare 
in  persons  whose  lungs  are  normal  except  for  the  condition  of 
the  bronchi. 

The  causes  which  produce  an  attack  of  asthma  may  act 
directly  on  the  mucous  membrane  of  the  bronchi,  or  indirectly 


Il6  ASTHMA. 

on  the  bronchi  tlirough  the  blood,  or  the  nervous  system.  So 
we  find  some  persons  who  never  have  an  attack  of  asthma  except 
when  exposed  to  a  directly  exciting  cause  ;  while  other  persons 
have  constantly  recurring  attacks  for  long  periods  of  time  with- 
out any  direct  cause  for  each  attack. 

Among  the  direct  causes  we  reckon  bronchitis,  inflammations, 
and  obstructions  of  the  nose,  climatic  influences,  dust,  vegeta- 
ble irritants,  chemical  vapors,  and  animal  emanations. 

The  ordinary  dust  floating  in  the  air,  the  odor  or  pollen  of 
many  plants  and  grasses  ;  the  vapors  of  pitch,  sulphur,  or  phos- 
phorus ;  the  peculiar  smell  of  dogs,  cats,  or  horses  are  familiar 
examples  of  direct  causes. 

The  efifect  of  climate  in  causing  asthma  is  very  marked  in 
some  persons.  This  effect  does  not  follow  any  definite  law,  but 
only  the  idiosyncrasy  of  the  individual.  It  does  not  matter 
whether  the  locality  is  warm  or  cold,  wet  or  dry,  low  or  elevated. 
For  nearly  ever}-^  asthmatic  person  we  can  find  some  one  place 
where  he  will  have  little  or  no  asthma. 

Of  all  the  causes  of  asthma,  however,  bronchitis  is  the  most 
frequent.  In  the  patients  who  belong  to  this  class  the  bronchitis 
constitutes  the  important  part  of  the  case,  for  if  the  attacks  of 
bronchitis  can  be  prevented  there  is  no  more  asthma. 

Of  late  years  much  attention  has  been  called  to  diseases  of 
the  nasal  passages  as  a  cause  of  asthma.  I  think  there  is  no 
question  that  they  do  constitute  one  of  the  causes.  But  it  is  go- 
ing a  great  deal  too  far  to  say  that  they  are  the  only  cause. 

Among  the  indirect  causes  of  asthma  we  enumerate  mental 
emotions,  indigestion,  hysteria,  gout,  heredity,  and  some  of  the 
skin  diseases.  But  it  must  be  confessed  that  we  are  often  unable 
to  say  why  a  previously  healthy  person  should  at  some  particular 
time,  without  any  exciting  cause,  begin  to  have  attacks  of  asthma. 

Morbid  Anatomy. — As  asthma  is  a  functional  disease  it  has  no 
lesions.  But  in  the  bodies  of  old  asthmatics  we  commonly  find 
the  morbid  changes  belonging  to  pulmonary  emphysema  and 
bronchitis. 

Symptoms. — -A  paroxysm  of  asthma  begins  with  a  feeling  of 
oppression  or  suffocation  about  the  upper  part  of  the  chest  which 
obliges  the  patient  to  sit  up  in  order  to  breatlie.  Tlie  feeling  of 
suffocation  continues,  and  the  patients  bring  into  play  all  the 
muscles  of  respiration  in  order  to  satisfy  the  hunger  for  air.  The 
skin  becomes  livid,  the  pulse  feeble^  and  the  patient's  face  shows 


ASTHMA.  117 

his  suffering.  If  we  listen  to  the  cliest,  we  henr  over  both  lungs 
the  sibilant  and  sonorous  breathing  caused  by  the  contraction  of 
the  bronchi.  Such  an  attack  lasts  for  hours  or  days.  During 
the  most  severe  attack  the  patients  look  as  if  they  might  die  at 
any  minute,  but  yet  after  a  time  the  attack  always  subsides. 

As  attacks  of  asthma  are  due  to  a  variety  of  causes,  so  they 
present  themselves  to  us  under  a  variety  of  clinical  aspects. 

1.  There  are  the  persons  who  never  have  astlima  unless  they 
have  an  attack  of  acute  bronchitis.  In  such  persons  we  liave  to 
look  at  the  bronchitis  as  the  real  disease,  while  the  asthma  is  only 
a  complication. 

2.  There  are  the  persons  who  only  have  asthma  at  certain 
times  of  year  and  in  certain  localities,  the  attacks  being  caused 
by  the  inhalation  of  the  pollen  or  odor  of  plants.  These  persons 
are  said  to  suffer  from  "hay  fever,"  "rose  cold,"  "autumnal 
catarrh,"  etc. 

3.  There  are  persons  in  whom  the  asthma  only  constitutes 
one  of  the  symptoms  of  pulmonary  emphysema.  These  cases  Avill 
be  described  with  emphvsema. 

4.  There  are  other  cases  in  which  the  asthma  occurs  by  itself 
as  a  pure  neurosis.  In  these  persons  the  disease  is  apt  to  be  very 
tenacious,  the  paroxysms  recurring  again  and  again  even  after 
considerable  intervals  of  improvement.  In  the  more  severe  cases 
the  bronchi  are  somewhat  contracted  and  the  breathing  labored 
nearly  all  the  time,  while  tlie  spasmodic  dyspnoea  recurs  at  reg- 
ular intervals.  The  patients  become  worn  out  by  the  constant 
dyspnoea,  the  face  is  one  of  suffering,  the  chest  is  bent  forward 
and  stooping,  the  nutrition  is  impaired,  the  whole  condition  is 
one  of  chronic  invalidism,  but  yet  life  is  prolonged  and  death  is 
usually  due  to  some  other  disease. 

Treatment. — The  objects  of  treatment  are  :  to  cut  short  the 
attacks  of  asthma,  and  to  prevent  the  recurrence  of  subsequent 
attacks. 

To  cut  short  an  attack  of  spasmodic  asthma  we  employ  sucii 
means  as  will  relax  the  spasmodic  contraction  of  the  walls  of  the 
bronchi.  Tliis  can  be  done  in  a  variety  of  ways  :  inhalation  of 
the  fumes  of  stramonium,  nitrate  of  potash,  chloroform,  ether, 
or  the  nitrite  of  amyl  ;  hypodermic  injections  of  morphine,  or 
chloral  hydrate  given  by  the  mouth  or  the  rectum  ;  the  use  of 
the  drugs  which  increase  the  production  of  mucus  from  the  bron- 
chi, such  as  lobelia  and  grindelia  robusta. 


Il8  HAEMOPTYSIS. 

To  prevent  the  recurrence  of  the  attacks  we  examine  into  the 
condition  of  the  nasal  passages  to  see  whether  there  is  disease 
there  which  may  cause  the  asthma.  We  inquire  into  the  liistory 
to  determine  whether  the  asthma  is  not  caused  by  bronchitis,  or 
by  the  pollen  or  odor  of  plants. 

If  the  astlima  is  a  pure  neurosis  a  considerable  number  of 
patients  can  find  a  climate  in  which  they  cease  to  suffer.  But 
the  selection  of  this  climate  has  to  be  made  experimentally  by 
each  patient.  There  is  no  rule  to  guide  us.  Each  person  has 
to  travel  from  place  to  place  until  they  find  the  particular  spot 
where  they  cease  to  have  asthma. 

For  the  patients  who  cannot  travel  the  most  efficient  treat- 
ment seems  to  be  the  long-continued  administration  of  the  iodide 
of  potash,  the  systematic  inhalation  of  compressed  air,  attention 
to  the  feeding,  disorders  of  digestion,  and  to  any  conditions 
which  impair  the  general  health. 

HEMOPTYSIS. 

Blood  which  is  coughed  up  comes  for  the  most  part  from  the 
bronchi  ;  less  frequently  from  the  pharynx,  from  eroded  vessels 
in  the  walls  of  cavities,  or  from  aneurisms  of  the  pulmonary 
artery  or  of  the  aorta. 

Haemoptyses  occur  so  frequently  with  the  tubercular  inflam- 
mations of  the  lungs  and  so  much  less  frequently  with  other 
morbid  conditions,  that  any  haemoptysis  is  regarded  with  a  good 
deal  of  suspicion. 

In  tubercular  inflammations  of  the  lungs  the  bleeding  is  from 
the  mucous  membrane  of  the  bronchi.  The  quantity  of  blood 
coughed  up  may  be  large  or  small.  The  bleeding  may  last  only 
a  few  minutes,  or  continue  a  number  of  days.  The  same  patient 
may  have  only  a  single  haemoptysis,  or  several.  There  seems  to 
be  no  period  in  the  course  of  tubercular  inflammation  of  the 
lungs  which  is  exempt  from  the  liability  to  bleeding  from  the 
mucous  membrane  of  the  bronchi.  Especially  is  it  to  be  re- 
membered that  either  large  or  small  haemoptyses  may  precede 
bv  a  considerable  interval  of  time  any  rational  symptoms  oi 
physical  signs  of  pulmonary  disease. 

In  the  older  cases  of  pulmonary  tuberculosis  in  which  cavities 
have  been  formed,  the  vessels  in  the  walls  of  these  cavities  ma} 
be  eroded,  with  an  escape  of  blood  which  is  large  and  dangerous 


H/EMOPTYSIS.  119 

The  very  frequency  of  the  association  of  haemoptysis  with 
pulmonary  tuberculosis  makes  it  important  to  enumerate  the 
other  conditions  under  which  haemoptysis  may  occur.  Tlie  fol- 
lowing are  the  forms  of  haemoptysis  wliich  occiu-  without  pul- 
monary tuberculosis  : 

1.  A  person  has  an  attack  of  haemoptysis  only  lasting  for  a 
short  time,  but  during  which  he  raises  a  considerable  quantity  of 
blood.  He  has  no  other  attacks  and  does  not  develop  any  pul- 
monary lesions.  The  bleeding  may  follow  severe  muscular  ex- 
ertion, great  mental  excitenient,  or  occur  without  discoverable 
cause. 

2.  In  women  haemoptysis  may  take  the  place  of  menstruation. 
Flint  says  that  lie  lias  seen  haemoptysis  occurring  at  regular  in- 
tervals for  four  years  after  the  suspension  of  the  menses.  But 
these  cases  must  be  looked  on  with  suspicion.  A  woman  may 
cough  up  blood  on  several  occasions  instead  of  menstruating  and 
then  go  on  to  have  lung  disease. 

3.  Chronic  naso-pharyngeal  catarrh  is  sometimes  attended 
with  occasional  small  haemoptyses. 

4.  Tliere  are  a  set  of  women  who  are  hysterical,  anaemic,  al- 
ways suffering  from  some  real  or  fancied  ailment,  who  from  time 
to  time  cough  up  a  little  blood. 

5.  It  is  said  that  pregnant  and  nursing  women  sometimes  have 
haemoptysis. 

6.  With  disease  of  the  aortic  and  mitral  valves,  especially  with 
mitral  stenosis,  bleeding  from  the  bronchi  is  of  frequent  occur- 
rence. In  the  course  of  the  heart  disease  tlie  patients  from  time 
to  time,  during  periods  of  several  days,  cough  up  clear  blood  in 
considerable  quantities. 

7.  Aneurisms  of  the  branches  of  the  pulmonary  artery  within 
the  lungs,  when  they  rupture,  cause  fatal  hemorrhage,  a  large 
part  of  the  blood  being  coughed  up. 

Aneurisms  of  the  arch  of  the  aorta  which  erode  the  trachea  or 
main  bronchi  may  rupture  into  the  trachea  or  bronchi  by  small  or 
large  openings.  With  the  small  openings  the  patients  cough  up 
a  little  blood  from  time  to  time,  while  part  of  the  escaped  blood 
is  inspired  into  the  lungs  and  sets  up  a  peculiar  form  of  pneu- 
monia. With  the  large  openings  the  blood  escapes  through  the 
trachea  in  enormous  quantities,  and  the  patients  bleed  to  death 
within  a  few  minutes. 

8.  Patients  wlio  suffer  from   emphysema  and  chronic   bron- 


I20  HEMOPTYSIS. 

chitis  not  infrequently  from  time  to  time  cough  up  small  quan- 
tities of  blood.  Much  less  often  such  patients  have  at  some  time 
a  large  bleeding  from  the  bronchi.  Part  of  this  blood  is  coughed 
up  at  once,  part  is  coagulated  in  the  large  bronchi  and  is  after- 
ward coughed  up  in  the  form  of  casts  of  these  tubes. 

9.  Sir  Andrew  Clark  [Lancet,  1889,  p.  841)  describes  a  form  of 
bleeding  which  he  calls  "arthritic  haemoptysis,"  of  which  he  says 
that  he  has  seen  some  twenty  cases.  He  lays  down  the  following 
propositions  :  There  occurs  in  elderly  persons,  free  from  ordinary 
diseases  of  the  heart  and  lungs,  a  form  of  haemoptysis  arising  out 
of  minute  structural  alterations  in  the  terminal  blood-vessels  of 
the  lung. 

These  vascular  alterations  occur  in  persons  of  the  arthritic 
diathesis,  resemble  the  vascular  alterations  found  in  osteo-ar- 
thritic  articulations,  and  are  themselves  of  an  arthritic  nature. 

Although  sometimes  leading  to  a  fatal  issue,  this  variety  of 
haemoptysis  usually  subsides  without  the  supervention  of  any 
coarse  anatomical  lesion  of  either  the  heart  or  the  lungs. 

This  variety  of  hemorrhage  is  aggravated  or  maintained  by 
the  frequent  administration  of  large  doses  of  strong  astringents, 
and  by  an  unrestricted  indulgence  in  liquids  to  allay  the  thirst 
which  the  liquids  themselves  create. 

The  treatment  which  appears  to  be  the  most  successful  in  this 
variety  of  haemoptysis  consists  in  diet  and  quiet,  in  the  restricted 
use  of  liquids,  and  the  stilling  of  cough  ;  in  calomel  and  salines, 
in  the  use  of  alkalies,  with  iodide  of  potassium,  and  in  frequently 
renewed  counter-irritation. 

ID.  Dr.  Flint  ("Practice  of  Medicine,"  p.  265)  says  that  he  has 
met  with  a  few  cases  of  persistent  bronchial  hemorrhage.  In  two 
of  these  cases,  after  expectoration  daily  more  or  less  of  a  sero- 
sanguinolent  liquid  during  several  months,  recovery  took  place 
under  the  use  of  tonics  and  hygienic  measures.  In  the  third 
case  the  hemorrhagic  expectoration  continued  for  six  years,  dur- 
ing which  time  repeated  examinations  of  the  chest  failed  to  dis- 
cover any  positive  signs  of  pulmonary  disease. 

II.  Severe  injuries  inflicted  upon  the  wall  of  the  thorax  may 
be  followed  by  the  expectoration  of  blood  for  hours,  or  days. 

Treatment. — In  managing  cases  of  bleeding  from  the  mucous 
mem'^rane  of  the  bronchi  it  is  important  to  bear  in  mind  that 
even  tlie  most  profuse  hemorrhages  are  seldom  fatal. 

The  methods  of  treatment  commonly  employed  are  :  the  appli- 


H.1iM0PTYSIS.  121 

cation  of  cold  to  the  chest,  the  temporary  ligation  of  one  of  the 
arms  or  legs,  the  internal  use  of  opium,  ergot,  hydrastis,  kramaria, 
tannic  acid,  gallic  acid,  acetate  of  lead,  persulphate  or  pernitrate 
of  iron,  or  of  calomel  or  of  the  saline  cathartics.  It  is  also  custo- 
mary to  keep  the  patients  very  quiet  while  the  bleeding  is  going 
on.  I  doubt  if  it  be  wise  to  be  too  anxious  and  energetic  in  the 
treatment  of  bleeding  from  the  mucous  membrane  of  the  bronchi. 
The  bleeding  will  regularly  stop,  no  matter  what  is  done.  The 
frequent  use  of  astringents  disorders  the  stomach,  the  insistence 
of  absolute  quiet  demoralizes  the  patient,  the  keeping  the  patients 
on  a  low  diet  unnecessarily  reduces  their  strength. 


EMPHYSEMA. 


Interlobular  Emphysema. 

Definition. — An  accumulation  of  air  in  the  connective  tissue 
septa  between  the  lobules  of  the  lung. 

Etiology. — Interlobular  emphysema  is,  I  think,  most  fre- 
quently seen  with  the  broncho-pneumonia  of  young  children.  It 
may  be  caused  by  any  violent  efforts  which  require  the  abrupt 
introduction  of  a  large  quantity  of  air  into  the  lungs,  and  its 
forcible  retention  therein  by  closure  of  the  glottis.  The  efforts 
in  parturition,  defecation,  raising  weights,  coughing,  paroxysms 
of  rage,  excessive  laughter,  and  hysterical  convulsions  have  all 
been  occasionally  followed  by  rupture  of  the  air-cells  and  inter- 
lobular emphysema. 

Morbid  Anatomy. — We  find  after  death  the  interlobular  septa 
infiltrated  with  air,  with  more  or  less  compression  of  the  paren- 
chyma of  the  lung.  The  air  may  find  its  way  from  the  lung  into 
the  mediastinum  and  thence  into  the  connective  tissue  of  the 
neck  and  the  wall  of  the  thorax. 

Symptoms. — There  seem  to  be  no  distinctive  rational  or  physi- 
cal symptoms  belonging  to  interlobular  emphysema.  But  in 
extreme  cases  it  is  said  to  have  caused  sudden  death. 

Vesicular    Emphysema. 

It  is  customary  to  speak  of  three  forms  of  vesicular  emphy- 
sema :  Compensating  emphysema,  senile  emphysema,  and  sub- 
stantive emphysema. 

I.  Compensating  Emphysema. — If  one  lung,  or  a  part  of  one 
lung,  is  so  changed  by  disease  that  it  can  only  partially  perform 
its  functions,  the  other  lung  becomes  increased  in  size  and  its  air- 
spaces are  dilated.  This  change  in  the  lung  is  a  healthy,  rather 
than  a  morbid  one,  and  gives  no  symptoms  of  disease. 


EMPHYSEMA.  123 

2.  Senile  Emphysema. — This  condition  is  often  described  as 
something  different  from  substantive  emphysema.  It  is  said  that, 
instead  of  there  being  an  abnormal  accumulation  of  air  in  the 
lungs,  these  organs  are  smaller  and  contain  less  air  than  normal. 
In  consequence  of  atrophy  of  the  alveolar  walls  the  air-cells 
coalesce  and  form  larger  air-spaces.  These,  however,  do  not  re- 
sult from  a  dilatation  of  the  alveoli,  but  from  a  gradual  shrinkage 
and  disappearance  of  the  lung  tissue. 

I  must  confess  that  such  descriptions  of  senile  emphysema  do 
not  correspond  with  the  lungs  which  I  have  seen.  I  believe  that 
the  anatomical  conditions  are  the  same  in  senile  as  in  substantive 
emphysema,  although  the  causation  and  clinical  history  are 
different. 

3.  Substantive  Emphysema. — The  definition  of  substantive 
emphysema  usually  given  is  that  it  is  a  morbid  condition  of  the 
lungs,  characterized  by  enlarged  capacity  of  the  air-cells,  with 
atrophy  of  their  walls,  and  obliteration  of  their  capillaries. 

I  should  define  the  disease,  on  the  contrary,  as  a  chronic 
interstitial  inflammation  of  the  lungs,  with  which  more  or  less 
dilatation  of  the  air-spaces  is  associated. 

Etiology. — Laennec,  who  was  the  first  to  describe  this  lesion, 
gives  the  causation  of  emphysema  as  follows  :  chronic  catarrh, 
plugging  by  mucus  of  small  bronchi,  consequent  obstruction  to 
the  passage  of  air,  conveyance  by  inspiration  of  air  past  the  ob- 
struction, failure  of  expiration  to  expel  this  air,  accumulation  of 
air  in  the  air-spaces,  dilatation  of  the  air-spaces — the  foundation 
of  the  disease,  therefore,  is  bronchitis. 

Louis  denies  this  mechanism,  because  the  symptoms  of  dilated 
air-cells  are  not  preceded  by  catarrh,  because  habitual  dyspnoea 
does  not  undergo  permanent  increase  after  acute  catarrh,  and  be- 
cause normal  inspiration  is  not  more  powerful  than  expiration. 

Dr.  Williams  maintains  the  catarrhal  basis  of  Laennec,  but 
supposes  that  while  the  air-cells  communicating  with  plugged 
bronchi  escape  distention,  those  adjoining,  and  possessed  of  free 
communication  with  the  trachea,  dilate  in  consequence  of  the 
extra  work  and  pressure  thrown  upon  them. 

Walshe  says  :  The  vesicular  dilatation  may  be  a  primary  or  a 
secondary  phenomenon  ;  that  is,  it  may  occur  independently  of 
any  acknowledged  form  of  statical  change  within  the  chest,  or  it 
may  supervene  on  some  actual  organic  mischief.  The  dilatation 
may  be  the  resultant  of  primary  nutritive  changes  in  the  actual 


124  EMPHYSEMA. 

walls  of  the  enlarged  vesicles,  affecting  both  their  statical  and 
dynamic  properties.  Or  these  cells,  being  in  their  own  nature 
healthy,  may  dilate  through  the  extra  strain  thrown  on  them  in 
consequence  of  the  inaction  of  neighboring  portions  of  lung. 

It  is  frequently  stated  that  playing  on  wind  instruments  or 
glass-blowing  causes  emphysema. 

If,  on  the  other  hand,  we  believe  that  emphysema  is  a  chronic 
interstitial  inflammation  of  the  lung,  and  that  the  dilatation  of 
the  air-spaces  is  not  the  primary  or  essential  part  of  the  morbid 
process,  then  we  class  emphysema  with  chronic  endocarditis,  en- 
darteritis, and  nephritis,  and  ascribe  it  to  the  same  cause. 

It  is  generally  agreed  that  the  disease  is  of  more  common 
occurrence  in  some  families  than  in  others. 

The  tradition  has  been  handed  down  from  one  text-book  to 
another  that  persons  who  have  emphysema  are  less  liable  than 
are  others  to  have  tuberculosis  of  the  lungs,  or  lobar  pneumonia. 
This  tradition  seems  to  have  no  foundation  in  fact,  tuberculosis 
and  emphysema  of  the  lung  are  frequently  associated. 

Morbid  Anatomy. — Both  lungs  are  regularly  increased  in  size. 
The  dilatation  of  the  air-spaces  may  be  so  great  as  to  be  evident 
to  the  naked  eye,  or  so  moderate  as  not  to  be  appreciable.  When 
we  examine  minutely  the  lungs  of  a  large  number  of  persons  who 
have,  during  life,  suffered  from  the  symptoms  of  emphysema,  we 
find  a  very  great  variety.  In  some  both  the  air-passages  and  air- 
vesicles  are  largely  dilated  ;  in  some  the  air-passages  alone  are 
dilated,  the  air-vesicles  remaining  of  normal  size  ;  in  some  neither 
the  air-passages  nor  vesicles  are  appreciably  dilated.  We  find 
also  when  we  compare  the  lungs  with  the  clinical  histories  which 
belong  to  them,  that  the  most  marked  symptoms  are  often  asso- 
ciated with  very  slight  degrees  of  dilatation  of  the  air-spaces,  and 
it  is  evident  that  the  severity  of  an  emphysema  is  not  to  be  meas- 
ured by  the  degree  of  dilatation  of  the  air-spaces. 

The  walls  of  the  air-spaces  are  thickened  in  some  parts  of  the 
lung,  thinned  in  others.  The  epithelial  cells  which  line  the  walls 
of  the  air-spaces  are  often  increased  in  size  and  number.  In  the 
walls  of  the  air-spaces  are  holes  with  sharp-cut  edges.  These 
holes  are  formed  in  the  spaces  between  the  capillaries,  some  are 
very  minute,  others  are  of  large  size.  It  is  evident  that  these 
holes  are  not  formed  by  the  stretching  of  the  air-spaces,  for  they 
are  found  in  small  air-spaces  as  well  as  in  large  ones.  They  con- 
stitute a  curious  and  important  part  of  the  lesion.     The  septa 


EMPHYSEMA.  12$ 

between  the  lobules,  the  connective  tissue  around  the  bronchi 
and  blood-vessels,  and  the  pulmonary  pleura  are  often  consider- 
ably thickened.  Very  frequently  there  are  adhesions  between 
the  pulmonary  and  costal  pleura.  The  mucous  membrane  of 
the  larger  bronchi  is  often  thickened. 

The  blood-vessels  of  these  lungs  can  be  readily  filled  with  an 
artificial  injection.  Neither  arteries,  capillaries,  nor  veins  are 
obstructed  or  obliterated.  But  in  the  walls  of  dilated  air-spaces, 
and  in  the  walls  of  those  in  which  there  are  holes  the  meshes  of 
the  capillary  plexus  are  larger  and  the  capillaries  are  farther 
apart  from  each  other. 

During  life,  however,  in  some  cases  of  emphysema  there  is 
an  obstruction  to  the  passage  of  blood  through  the  lungs,  and 
consequently  dilatation  and  hypertrophy  of  the  right  ventricle 
of  the  heart  and  venous  congestion  of  the  pia  mater,  stomach, 
small  intestine,  liver,  spleen,  and  kidneys.  These  evidences  of 
venous  congestion  often  exist  in  cases  in  which  the  air-spaces 
are  but  very  little  dilated. 

It  is  not  often  that  we  see  a  case  of  advanced  emphysema 
after  death  without  finding  at  the  same  time  chronic  endarteritis, 
endocarditis,  or  nephritis. 

Symiptoyns. — Physical  Signs.  In  the  lesser  degrees  of  emphy- 
sema there  is  no  change  in  the  shape  of  the  thorax.  In  the 
more  advanced  cases  there  is  a  prominence  of  the  upper  part  of 
the  sternum  and  of  the  costal  cartilages.  In  patients  who  have 
suffered  much  from  dyspnoea  the  hypertrophy  of  the  muscles 
which  move  the  thorax  contrasts  with  the  general  emaciation  of 
the  patients.  In  the  cases  in  which  there  is  great  dilatation  of 
the  air-spaces  the  chest  assumes  the  so-called  barrel  shape. 

The  percussion  sound  may  remain  unchanged  for  a  consider- 
able length  of  time.  When  it  is  changed  the  change  is  either 
to  a  rather  dull  note  of  wooden  quality,  or  to  exaggerated  reso- 
nance of  either  vesicular,  or  vesiculo-tympanitic  quality. 

The  respiratory  murmur  is  feeble  ;  or  there  is  feeble  inspira- 
tion with  longer,  louder,  low-pitched  expiration ;  or  both  inspira- 
tion and  expiration  may  be  exaggerated,  loud,  and  high-pitched. 

The  pleuritic  adhesions  give  more  or  less  dulness  on  percus- 
sion. When  the  bronchi  are  contracted  there  is  sibilant  and 
sonorous  breathing. 

Rational  Symptoms.  There  are  many  persons  in  whom  sub- 
stantive emphysema  is  developed  and  continues  for  many  years 


126  EMPHYSEMA. 

without  giving  rise  to  any  symptoms,  and  yet,  even  in.  sucli  per- 
sons, it  is  often  possible  to  be  pretty  sure  of  the  presence  of  the 
disease,  because  they  are  persons  whose  general  condition  and 
age  are  such  as  are  usually  associated  with  emphysema. 

There  are  many  persons  in  whom  the  associated  chronic 
endocarditis  or  endarteritis,  or  nephritis,  gives  such  marked 
symptoms  that  the  emphysema  passes  unnoticed. 

In  some  persons  tlie  emphysema  gives  after  a  time  dyspnoea 
on  exertion,  but  without  bronchitis,  or  disturbance  of  the  gen- 
eral healtli.  These  are  persons  past  middle  age,  who  do  not 
consider  themselves  invalids,  who,  on  the  contrar}',  are  often 
strong  and  robust,  and  in  whom  the  emphysema  is  only  an  in- 
convenience. 

In  some  persons  the  principal  symptoms  are  those  belonging 
to  the  associated  acute  and  chronic  bronchitis.  The  attacks  of 
acute  bronchitis  may  be  mild,  lasting  for  a  few  days  or  a  few 
weeks,  with  cough,  mucous  expectoration,  sometimes  haemopty- 
sis, asthmatic  breathing,  and  a  febrile  movement.  Or  they  may 
be  severe  and  last  for  several  months,  with  continued  cough, 
asthmatic  breathing,  fever,  venous  congestion,  dropsy,  and  loss 
of  flesh  and  strength.  The  chronic  bronchitis  continues  year 
after  year,  better  every  summer  and  worse  every  winter.  The 
patients  have  a  cough  with  mucous,  or  muco-purulent  expectora- 
tion, sometimes  with  small  haemoptyses.  They  are  always  a  lit- 
tle sliort  of  breath  when  they  exert  themselves.  After  a  time 
they  have  attacks  of  spasmodic  asthma.  In  the  unfavorable 
cases  the  dyspnoea  on  exertion  becomes  more  constant  and  more 
decided,  venous  congestion  and  dropsy  are  established,  and  the 
patients  lose  flesh  and  strength. 

In  some  persons  the  prominent  feature  in  the  disease  is  the 
liability  to  attacks  of  spasmodic  asthma,  which  often  are  fre- 
quently repeated  and  of  long  duration.  These  attacks  are  some- 
times due  to  contraction  of  the  bronchi,  and  then  we  get  sibilant 
and  sonorous  breathing  ;  or  they  are  due  to  contraction  of  the 
arteries  belonging  to  the  aortic  system  and  there  is  a  radial 
pulse  of  increased  tension  ;  or  they  are  due  to  contraction  of  the 
branches  of  the  pulmonary  artery  and  then  there  is  neither  sibil- 
ant and  sonorous  breathing,  nor  a  pulse  of  high  tension. 

In  some  persons  the  principal  symptom  is  the  constant  dysp- 
noea. The  difficult  breathing  is  at  first  only  developed  by  exer- 
tion, later  it  becomes  more  constant  and  is  made  worse  bv  slight 


EMPHYSEMA.  12/ 

exertion,  bv  indigestion,  and  by  broncliitis.  Finully,  in  the  bad 
cases,  the  dyspnoea  is  constant  and  distressing.  Tlie  patients 
constantly  feel  the  need  of  air  and  are  always  overusing  the 
muscles  of  respiration  in  order  to  satisfy  this  need.  General 
venous  congestion  is  gradually  established  as  well  as  cyanosis  of 
the  skin,  clubbing  of  the  fingers,  congestion  of  the  stomach, 
small  intestine,  liver,  and  kidneys  ;  dilatation  and  liypertrophy 
of  the  right  ventricle  of  the  heart  and  general  dropsy.  The  nu- 
trition of  the  patients  suffers  and  they  become  emaciated,  feeble, 
and  anaemic.  It  is  not  easy  to  tell  how  much  of  this  dyspnoea 
depends  upon  the  anatomical  changes  in  the  lungs,  how  much 
upon  contraction  of  the  branches  of  the  pulmonary  artery,  and 
how  much  upon  contraction  of  the  arteries  belonging  to  the 
aortic  system.  There  are  rare  and  fatal  cases  in  which  there  are 
no  pulmonary  symptoms.  The  patients  lose  flesli  and  strength 
and  become  aneemic  without  any  evident  cause  for  tlieir  ill- 
health.  After  going  on  in  this  way  for  some  time  they  begin  to 
have  attacks  of  contraction  of  the  arteries  with  headache,  sleep- 
lessness, delirium,  stupor,  muscular  twitchings,  and  vomiting,  or 
a  dyspnoea  like  that  seen  in  chronic  nephritis.  They  die  within 
a  few  months  after  they  have  begun  to  have  the  attacks  of  con- 
traction of  the  arteries. 

In  some  persons,  after  emphysema  has  existed  for  some  time 
with  more  or  less  marked  symptoms,  chronic  miliary  tubercu- 
losis is  slowly  established. 

Emphysema  by  itself  proves  fatal  only  in  a  moderate  num- 
ber of  cases.  Death  is  usually  due  to  some  complicating  or 
intercurrent  disease. 

Treatment.— "YX^Q  conditions  which  call  for  treatment  are  : 
The  morbid  condition  of  the  lung,  the  loss  of  nutrition,  the  bron- 
chitis, the  constant  dyspnoea  and  the  spasmodic  dyspnoea  ;  the 
contraction  of  the  arteries,  and  the  venous  congestion. 

The  emphysema  is  favorably  affected  by  an  out-of-door  life 
in  a  suitable  climate  ;  by  abstinence  from  alcohol,  tobacco, 
sugars,  and  starches  ;  by  the  use  of  fats  and  by  overfeeding 
with  the  stomach-tube  ;  and  by  methodical  inhalations  of  com- 
pressed air.  All  of  these  measure*;  are  also  of  service  in  improv- 
ing the  nutrition  of  the  patients  and  in  helping  them  to  get  rid 
")f  chronic  bronchitis. 

The  constant  dyspnoea  is  due  to  the  changes  in  the  lungs,  and 
5  then  to  be  treated  by  the  same  means  which   are  used  to  con- 


128  THE   LUNGS. 

trol  the  emphysema  ;  or  it  is  due  to  the  complicating  contrac- 
tion of  the  arteries,  and  is  then  to  be  treated  by  the  drugs  which 
dilate  the  arteries — nitro- glycerine,  potassium  iodide,  or  chloral 
hydrate. 

The  attacks  of  spasmodic  dyspnoea  are  due  to  : 
(a)  Spasmodic  contraction  of  the  muscular  coat  of  the  bron- 
chi. This  can  be  relieved  by  the  inhalation  of  the  fumes  of  stra- 
monium, nitrate  of  potash,  chloroform,  or  ether  ;  by  the  admin- 
istration of  chloral  hydrate,  potassium  iodide,  belladonna,  or 
opium. 

(d)  Congestion  of  the  walls  of  the  bronchi.  This  can  be  re- 
lieved by  drugs  which  increase  the  production  of  mucus,  such 
as  lobelia  and  grindelia  robusta  ;  by  drugs  which  stimulate  the 
heart,  such  as  caffeine,  convallaria,  and  digitalis  ;  or  by  the  ap- 
plication of  dry  cups  to  the  walls  of  the  chest, 

(c)  Contraction  of  the  small  arteries.  This  can  be  relieved 
by  the  drugs  which  dilate  the  arteries,  such  as  nitrite  of  amyl, 
nitro-glycerine,  chloral  hydrate,  potassium  iodide,  or  opium. 

(d)  Inflammation  of  the  nasal  passages.  This  is  to  be  treated 
by  local  applications. 

Actinomycosis  of  the  Lung. 

The  following  account  of  actinomycosis  of  the  lung  is  taken 
from  a  compilation  of  thirty-four  cases  made  by  Dr.  Hodenpyl. 
My  own  experience  is  limited  to  two  cases. 

Definition. — Pulmonary  actinomycosis  is  a  chronic  infectious 
disease  of  the  lungs  dependent  upon  the  presence  of  actino- 
myces. 

Etiology. — Information  concerning  the  characters  and  causa- 
tion of  actinomycosis  in  general  are  given  in  the  article  on  that 
disease.  So  far  as  the  lungs  are  concerned  the  living  germ 
seems  to  be  inhaled  into  the  bronchi.  The  majority  of  the  cases 
were  in  young  adults  ;  the  youngest  patient  was  nine  years  old, 
the  oldest  sixty-three. 

Morbid  Anatomy. — The  lesions  are  unilateral  in  about  the  pro- 
portion of  three  to  one.     They  may  be  classified  into  two  groups. 

I.  There  are  cases  with  the  symptoms  of  chronic  general 
bronchitis  with  the  germ  present  in  the  sputum,  but  in  which  no 
autopsy  is  made.  Whether  in  these  cases  there  is  no  lesion  but 
that  of  chronic  bronchitis  we  cannot  certainly  tell. 


THE    LUNGS.  1 29 

2.  There  is  a  broncho-pneumonia  of  a  peculiar  type,  which 
involves  part  of  a  lobe,  or  an  entire  lung.  The  large  bronchi 
are  coated  with  muco-pus.  The  small  bronchi  contain  pus,  their 
walls  are  thickened,  they  are  surrounded  by  zones  of  peri-bron- 
chitic  pneumonia.  In  some  of  the  small  bronchi  there  are 
growths  of  new  connective  tissue  partly  filling  them.  In  the 
peri-bronchitic  zones  of  pneumonia  the  walls  of  the  air-spaces 
are  thickened  and  their  cavities  filled  with  new  connective  tissue. 
Between  these  zones  is  a  diffuse  hepatization  of  ordinary  exuda- 
tive type.  There  are  adhesions  between  the  pulmonary  and 
costal  pleura. 

There  are  often,  in  addition,  sacculated  collections  of  pus  in 
the  pleural  cavity,  which  may  perforate  through  the  skin,  or 
through  the  diaphragm.  The  ribs,  sternum,  or  vertebrae  may 
be  eroded.  The  opposite  lung,  the  pericardium,  or  the  heart 
may  become  involved.  There  may  be  secondary  inflammations 
of  the  abdominal  organs,  or  of  the  brain.  In  one  case  the  in- 
flammation penetrated  the  portal  vein  and  there  were  metastases 
all  over  the  body. 

Sytnptoins. — A  febrile  movement  is  present  in  nearly  all  the 
cases.  Usually  it  is  one  of  the  first  symptoms,  but  sometimes  it 
does  not  come  on  until  later  in  the  course  of  the  disease. 

Cough  is  regularly  the  first  symptom,  and  continues  through- 
out the  disease.  It  is  accompanied  with  an  abundant  muco- 
purulent, often  fetid,  expectoration,  and  sometimes  contains 
actinomyces.  Haemoptyses  were  not  observed,  although  the 
sputa  were  sometimes  stained  with  blood.  The  patients  lose 
flesh  and  strength,  at  first  slowly,  later,  as  abscesses  are  formed 
and  septic  poisoning  established,  they  run  down  more  rap- 
idly. 

The  physical  signs  are  those  of  bronchitis,  of  broncho-pneu- 
monia, of  phthisis,  or  of  empyema. 

The  average  duration  of  the  disease  is  ten  months  ;  the  short- 
est case  lasted  four  months,  and  the  longest  was  still  living  after 
a  duration  of  several  years. 

Of  the  thirty-four  cases  all  died  except  two. 

Diagnosis. — The  disease  is  liable  to  be  confounded  with  fetid 
bronchitis,  gangrene  of  the  lung,  broncho-pneumonia,  or  pul- 
monary phthisis.  The  only  positive  diagnostic  symptom  seems 
to  be  the  presence  of  the  actinomyces  in  the  sputa  or  in  the  pus 
from  the  pleura.  .,::,, 


130  THE   LUNGS. 

Treatment. — There  seems  to  be  no  way  of  directly  improving" 
this  disease  of  the  lunes. 


Malignant  Growths  in  the  Lungs. 

We  include  under  this  head  the  primary  and  secondary  tumors 
formed  in  the  lungs  which  belong  to  the  classes  of  carcinoma, 
sarcoma,  and  lymphoma. 

Morbid  Anatomy. — The  carcinomata  of  the  lung  are  either  sec- 
ondary or  primary.  The  secondary  tumors  follow  the  anatomical 
type  of  the  primary  tumor.  The  primary  tumors  consist  of  a 
stroma  enclosing  spaces  lined  with  cylindrical  epithelium,  the 
growth  apparently  beginning  in  tlie  small  bronchi.  Whether  the 
tumors  are  primarv  or  secondary  we  find  that  they  may  be  de- 
veloped in  such  a  way  as  to  compress  the  bronchi,  or  be  asso- 
ciated with  exudative  and  productive  inflammation  in  such  a  way 
as  to  consolidate  large  portions  of  the  lung  ;  or  be  associated  with 
suppurative  and  destructive  inflammation  in  such  a  way  that  ab- 
scesses are  formed  ;  or  involve  the  pleura  so  that  large  collections 
of  serum  are  formed  in  the  pleural  cavities. 

The  sarcomata  of  the  lung  are  secondary  tumors.  Tliey  usu- 
ally are  in  the  form  of  nodules  scattered  through  the  lung,  or  of 
tumors  which  compress  the  bronchi,  or  of  tumors  in  the  pleura 
with  serum  in  the  pleural  cavities. 

The  lymphomata  begin  in  the  bronchial  glands  and  infiltrate 
the  lungs  from  the  root  outward,  following  the  track  of  the 
bronchi  or  of  the  interlobular  septa. 

Symptoms. — While  in  some  cases  the  symptoms  are  obscure,  in 
others  they  are  well  defined.  They  are  apt  to  follow  one  of  three 
types  : 

1.  The  most  marked  symptom  is  dyspnoea  due  to  pressure  on 
the  bronclii.  The  dyspnoea  is  developed  slowly  and  is  brought 
on  by  exertion.  It  becomes  more  and  more  distressing  until 
finally  the  patient  can  hardly  move  at  all  without  bringing  on  the 
bad  breathing. 

The  physical  signs  are  either  tubular  breathing,  or  diminished 
breathing  over  the  lung  corresponding  to  the  compressed  bronchi. 
The  patients  lose  flesh  and  strength,  at  first  slowly,  later  very 
rapidly. 

2.  The  symptoms  are  those  of  a  chronic  inflammation  of  the 
lung.      The   patients   have   cough,    dyspnoea,    muco-purulent    or 


THE    LUNGS.  131 

bloody  expectoration,  a  febrile  movement,  pains  in  the  chest,  the 
physical  signs  of  bronchitis  and  of  consolidation  of  the  lung,  and 
gradual  loss  of  flesh  and  strength. 

3.  The  symptoms  are  those  of  a  pleurisy  with  effusion,  but  it 
is  a  pleurisy  which  does  not  improve  under  treatment.  The  serum 
is  apt  to  be  blood  stained,  but  is  not  always  so,  it  reaccumulates 
after  it  has  been  drawn  off,  the  patients  steadilv  lose  flesh  and 
strength,  or  there  may  be  a  combination  of  the  signs  of  consoli- 
dation of  tlie  lung  with  that  of  fluid  in  the  pleura. 


THE  HEART. 


In  examining  any  person  who  is  suspected  of  having  a  dis- 
ease of  tlie  heart  we  follow  a  certain  routine  in  the  physical 
examination.  We  determine  the  size  of  the  heart,  the  character 
of  its  impulse,  the  rhythm  of  its  contractions  and  dilatations,  the 
character  of  the  heart-sounds,  and  tlie  presence  or  absence  of 
murmurs. 

The  size  of  tlie  heart  is  made  out  by  simple,  or  by  ausculta- 
tory percussion,  and  by  locating  the  apex-beat.  We  determine 
the  upper,  the  left,  and  tlie  right  edges,  and  the  apex-beat. 

The  upper  border  of  the  heart  should  be  at  the  third  left  cos- 
tal cartilage.  Tiie  left  border  is  at  the  left  nipple.  The  right 
border  is  one  inch  to  the  right  of  the  sternum.  The  apex-beat 
is  in  the  fifth  interspace,  midway  between  the  left  edge  of  the 
sternum  and  the  nipple,  three  and  one-fourth  inches  from  the 
middle  of  the  sternum.  A  small  portion  of  the  anterior  surface 
of  the  pericardium,  usually  corresponding  to  the  fourth  left 
interspace  and  the  fifth  left  cartilage,  is  uncovered  by  the  lungs, 
and  gives  more  decided  dulness  on  percussion  than  the  rest  of 
the  precordial  area. 

It  is  comparatively  easy  in  this  way  to  make  out  any  increase 
in  the  size  of  the  heart,  but  a  diminution  in  its  size  is  much  more 
difficult  to  determine. 

The  apex-beat  can  usually  be  felt  by  the  hand,  but  in  many 
healthy  persons  does  not  communicate  a  perceptible  shock  to 
the  chest-wall.  Its  position  must  then  be  determined  by  the 
stethoscope.  The  force  of  the  impulse  is  temporarily  increased 
by  muscular  exertion,  by  rapid  respiration,  by  digestion,  and  by 
mental  emotions.  It  is  decreased  by  any  disease  which  impairs 
nutrition. 

Myocarditis,  degeneration  of  the  wall  of  the  heart,  an  excess 
of  fat  about  the   heart,  and  fluid  in  the   pericardial  sac  diminish 


134  THE   HEART. 

the  force  of  the  impulse.  There  are  often  cases  of  abnormally 
feeble  impulse  for  which  it  is  diflficult  to  account. 

The  force  of  the  impulse  is  increased  in  some  of  the  cardiac 
neuroses,  with  hypertrophy  of  the  ventricles,  with  contraction  of 
the  arteries,  and  with  some  of  the  acute  inflammations  of  the 
pericardium  and  endocardium. 

Dilatation  of  the  ventricles  changes  the  character  of  the  im- 
pulse ;  instead  of  a  circumscribed  apex-beat  there  is  a  diffuse, 
heaving  impulse  over  the  whole  precordial  region. 

The  rhythm  of  the  alternate  contractions  and  dilatations  of 
the  heart  should  be  perfectly  regular.  In  some  healthy  persons, 
however,  there  is  a  regular  intermission  of  the  ventricular  sys- 
tole. The  same  thing  may  occur  in  the  tubercular  meningitis  of 
children.  In  some  persons  the  heart-sounds  are  reduplicated  ; 
either  the  systolic,  or  the  diastolic  sound,  or  both,  may  be  redu- 
plicated ;  this  is  said  to  be  due  to  a  want  of  synchronism  between 
the  action  of  the  two  sides  of  the  heart. 

The  heart's  action  becomes  irregular  with  valvular  disease, 
dilatation  and  hypertrophy  of  the  ventricles,  fatty  degeneration 
of  the  wall  of  the  heart,  myocarditis,  pericarditis,  and  the  cardiac 
neuroses. 

The  Normal  Heart-sounds. — -The  contraction  and  dilatation  of 
the  cavities  of  the  heart  are  accompanied  with  certain  sounds. 
The  first  sound  is  synchronous  with  the  systole  of  the  ventricles, 
the  apex-beat,  and  the  closure  of  the  auriculo-ventricular  valves  ; 
it  is  loudest  at  the  apex.  After  the  first  sound  is  a  short  interval 
of  silence,  the  post-systolic  silence.  The  second  sound  is  syn- 
chronous with  the  closure  of  the  aorta  and  pulmonary  valves  ;  it 
is  most  distinct  over  the  third  cartilage  and  the  middle  of  the 
sternum.  After  the  second  sound  is  another  interval  of  silence, 
the  post-diastolic  silence.  If  the  period  of  an  entire  revolution 
of  the  heart  from  the  beginning  of  one  first  sound  to  the  begin- 
ning of  the  next  first  sound  be  divided  into  ten  equal  parts,  the 
duration  of  the  several  periods  of  sound  and  silence  will  be  as 
follows:  First  sound,  4;  first  silence,  i  ;  second  sound,  2  ;  second 
silence,  3. 

When  we  listen  to  the  heart-sounds  we  notice  the  loudness, 
the  distinctness,  and  the  quality. 

Murmurs  are  pericardial  or  endocardial. 

Pericardial  murmurs  are  produced  by  the  rubbing  of  opposed 
surfaces  of  the  pericardium  coated  with  fibrin  or  with  adhesions. 


THE   HEART. 


135 


The  sound  may  be  of  a  rubbing,  grating,  creaking,  squeaking,  or 
whistling  character  ;  or  it  maybe  soft  and  blowing  like  an  endo- 
cardial murmur.  The  sound  may  be  very  loud,  or  so  faint  as  to 
be  hardly  audible.  Such  murmurs  are  heard  with  the  first  or 
second  sounds,  or  with  both  :  less  frequently  they  are  pre-sys- 
tolic  ;  but  they  are  not  always  exactly  synchronous  with  the 
heart-sounds. 

There  is  no  fixed  point  of  intensity  for  pericardial  murmurs, 
but  they  are  most  frequently  heard  over  the  base.  Usually  the 
sound  seems  to  be  superficial.  Such  murmurs  are  distinguished 
from  endocardial  murmurs  by  their  quality,  their  superficial 
character,  their  limitation  to  a  small  area,  their  changeableness 
in  position  and  intensity  from  hour  to  hour,  their  greater  inten- 
sity when  the  patient  leans  forward  or  fills  the  lung,  their  greater 
intensity  if  we  press  on  the  chest-wall,  their  want  of  synchronism 
with  the  heart-sounds.  But  in  some  cases  it  is  hardly  possible 
to  distinguish  between  pericardial  and  endocardial  murmurs. 

Endocardial  murmurs  are  produced  by  : 

(a)  Change  in  the  valves,  by  which  they  are  rendered  rough, 
stenosed,  or  insufficient. 

((^)  Ventricular  lesions.  Inflammation  of  the  endocardium  or 
of  tlie  chordae  tendinse,  abnormal  tendinous  cords  extending 
across  the  ventricles,  or  thrombi  in  the  ventricles.  Ventricular 
murmurs  are  systolic,  their  point  of  maximum  intensity  is  at  the 
apex  ;  they  are  not  transmitted. 

(<r)  Dilatation  of  the  right  auricle  and  the  right  ventricle. 
Such  dilatations  disturb  the  circulation  in  the  pulmonary  artery 
and  aorta.  They  cause  a  systolic  murmur,  with  its  point  of 
maximum  intensity  at  the  second  left  intercostal  space,  or  at  the 
apex.  The  murmur  can  be  heard  in  some  persons  at  all  times  ; 
in  others,  only  after  muscular  exertion  ;  in  others,  only  when 
they  are  anaemic. 

Pericarditis. 

Lesions. — The  inflammations  of  the  pericardium  resemble 
those  of  the  pleura. 

They  begin  acutely  or  subacutely,  and  then  run  an  acute, 
subacute,  or  chronic  course.  There  is  a  greater  disposition  to 
bleeding  from  the  inflamed  surfaces  than  is  the  case  in  pleurisy. 
The  inflammation  regularly  begins  at  the  base  of  the  heart  and 
then  extends  over  the  greater  part  of  the  pericardium. 


136  THE   HEART. 

We  distinguish  : 

1.  Pericarditis  with  the  Production  of  Fibrin. — The  pericardium 
is  congested,  or  even  studded  with  minute  hemorrliages.  Its 
surface  is  coated  witli  a  tliin  film  of  fibrin,  or  with  large,  rough 
masses,  which  glue  together  the  opposed  surfaces  of  the  pericar- 
dium. If  the  inflammation  is  protracted  the  pericardium  itself 
becomes  thickened  and  infiltrated  with  cells,  and  the  wall  of  the 
heart  may  also  undergo  inflammatory  changes. 

If  the  patient  recovers  the  fibrin  is  absorbed  and  the  pericar- 
dium returns  to  its  normal  condition  ;  or  there  is  a  growth  of 
new  connective  tissue,  which  forms  permanent  thickenings  and 
adhesions. 

2.  Pericarditis  with  the  Production  of  Fibrin  and  Serum. — The 
pericardium  is  coated  with  fibrin  and  there  is  an  effusion  of  se- 
rum in  the  pericardial  sac.  The  serum  accumulates  at  first  be- 
tween the  floor  of  the  pericardium  and  the  lower  surface  of  the 
heart,  as  it  increases  it  distends  the  pericardial  sac  in  all  direc- 
tions, pushing  the  heart  upward  and  forward.  The  pericardial 
sac  may  be  so  much  distended  as  to  compress  the  trachea,  the 
left  bronchus,  the  oesophagus,  or  the  aorta.  If  the  patients  re- 
cover, the  serum  and  fibrin  are  absorbed,  but  permanent  thick- 
enings and  adhesions  of  connective  tissue  are  left. 

3.  Pericarditis  with  the  Production  of  Fibrin^  Serum,  and  Pus. — 
This  variety  may  have  the  purulent  character  from  the  outset,  or 
it  may  begin  as  one  of  the  forms  just  described,  and  afterward 
assume  the  purulent  character.  The  inflammation  is  apt  to  run 
a  chronic  course.  The  pericardial  sac  contains  a  lai-ge  quantity 
of  purulent  serum  ;  the  pericardium  is  coated  with  fibrin,  thick- 
ened and  infiltrated  with  cells  ;  the  walls  of  the  heart  may  be 
the  seat  of  interstitial  myocarditis.  The  trachea,  left  bronchus, 
oesophagus,  or  aorta  may  be  compressed.  The  serum  may  be 
absorbed,  and  the  fibrin  and  pus  undergo  cheesy  degeneration, 
or  there  may  be  a  deposition  of  the  salts  of  lime  in  the  thickened 
pericardium. 

Causes. — Altogether  the  most  frequent  cause  of  pericarditis  is 
acute  articular  rheumatism.  With  scarlatina  and  the  other  infec- 
tious diseases  it  is  not  uncommon.  It  complicates  chronic  ne- 
phritis, and  sometimes  is  the  first  symptom  to  call  attention  to 
the  nephritis.  A  double  pleurisy  is  regularly  accompanied  with 
pericarditis,  while  with  a  single  pleurisy  this  is  not  often  the  case. 
Lobar   pneumonia  is   often    complicated    by  pericarditis.      This 


THE   HEART.  1 37 

happens  more  often  in  some  years  than  others.  There  are  \vin- 
ters  during  which  a  considerable  number  of  deaths  from  pneu- 
monia seem  to  be  due  to  tiie  pericarditis.  Primary  pericarditis 
seldom  occurs. 

Symptoms. — In  pericarditis  with  the  production  of  fibrin  alone 
the  regular  physical  signs  are  the  friction-sound  and  the  in- 
creased frequency  of  the  heart's  action.  But  with  large  quanti- 
ties of  fibrin  the  heart  dulness  is  symmetrically  enlarged. 

In  pericarditis  with  the  effusion  of  serous  or  purulent  fluid 
the  physical  signs  vary  with  the  quantity  of  fluid.  With  small 
quantities  of  fluid  the  extent  of  the  precordial  dulness  is  un- 
changed, but  the  dulness  approaches  flatness. 

With  distention  of  the  pericardial  sac  by  serum  the  area  of 
precordial  dulness  is  enlarged  in  all  directions.  The  anterior 
w^all  of  the  chest  may  be  bulged  out.  The  apex-beat  is  carried 
upward.  Before  the  appearance  of  the  fluid  and  after  its  absorp- 
tion there  may  be  a  friction-sound.  The  physical  signs  due  to 
the  pericarditis  may  be  complicated  by  murmurs  due  to  a  pre- 
existing endocarditis. 

The  rational  symptoms  of  pericarditis  are  pain,  rapid,  feeble, 
and  irregular  heart-action,  rapid  and  oppressed  breathing,  venous 
congestion  of  the  skin  and  viscera,  dysphagia,  a  febrile  move- 
ment, and  prostration. 

The  cases  with  exudation  of  fibrin  alone  give  the  fewest  and 
least  severe  symptoms  ;  those  with  large  exudations  of  serum 
give  very  marlved  symptoms  ;  those  with  serum,  fibrin,  and  pus 
are  the  worst. 

In  many  of  the  milder  cases  it  is  only  by  the  physical  signs 
that  we  recognize  the  existence  of  the  disease. 

Sometimes,  however,  the  symptoms  of  a  dry  pericarditis  are 
so  marked  as  to  mask  those  of  a  lobar  pneumonia. 

The  cases  with  large  effusions  of  fluid  do  not  seem  to  be  as 
common  in  the  United  States  as  in  some  other  countries. 

The  prognosis  in  the  milder  cases  depends  more  upon  the  pri- 
mary disease  than  upon  the  pericarditis.  With  tlie  large  serous 
and  purulent  effusions,  however,  the  pericarditis  becomes  in 
itself  a  dangerous  lesion. 

Treatment. — For  a  rheumatic  pericarditis  the  treatment  of  the 
rheumatism  with  salicylate  of  soda,  etc.,  is  a  matter  of  much  im- 
portance. With  pneumonia  and  with  double  pleurisy  the  treat- 
ment of  these  conditions  is  necessary. 


138  THE   HEART. 

For  the  pericarditis,  dry  cups,  blisters,  or  continuous  cold 
over  the  precordial  region,  are  of  service.  The  feeble  and  dis- 
turbed heart-action  requires  cardiac  stimulants.  If  there  is  a 
considerable  quantity  of  fluid  in  the  pericardial  sac  we  use  ca- 
thartics or  diuretics,  or  draw  off  the  fluid  with  the  aspirator. 
The  point  of  election  at  which  to  insert  the  trocar  is  the  fifth 
left  interspace,  about  two  or  three  and  a  half  inches  from  the 
sternum. 

Endocarditis. 

The  endocardium  is  a  connective-tissue  membrane  which  lines 
the  cavities  of  the  heart  and  forms  the  larger  part  of  the  valves. 
It  is  a  thin,  dense,  and  elastic  membrane,  containing  but  few 
blood-vessels.  It  becomes  the  seat  of  productive  rather  than  of 
exudative  inflammation.  During  foetal  life  the  endocardium  of 
the  right  heart  is  inflamed  ;  after  birth  usually  the  endocardium 
of  the  left  heart.  The  valves  are  the  portion  of  the  endocardium 
most  frequently  affected,  but  that  which  lines  the  auricles  and 
ventricles  and  covers  the  papillary  muscles  may  be  inflamed  in- 
dependently. 

We  distinguish  : 

Acute  endocarditis. 

Malignant  endocarditis. 

Chronic  endocarditis. 


ACUTE    ENDOCARDITIS. 

Lesions. — i.  The  valves  are  swollen  and  succulent  ;  the  base- 
ment-substance and  cells  are  swollen  ;  the  surface  of  the  valves 
remains  smooth.  As  the  valves  are  swollen  they  are  also  short- 
ened and  insufficient. 

2.  The  valves  are  not  only  swollen  but  there  is  an  extensive 
growth  of  their  connective-tissue  cells,  resulting  in  the  formation 
of  ulcers  and  of  vegetations.  On  the  roughened  surfaces  of  the 
valves  fibrin  from  the  blood  coagulates  in  considerable  masses. 
Portions  of  the  vegetations  may  become  detached,  pass  into  the 
aorta,  and  become  lodged  in  the  smaller  arteries  as  emboli. 

Causes. — Acute  endocarditis  is  usually  a  complication  of  rheu- 
matism, of  scarlatina,  or  of  chorea. 

Symptoms. — The  physical  signs  are  due  to  the  insufficiency  and 


THE    HEART.  I  39 

roughening  of  the  valves.  Scj  we  liave  a  mitral  systolic,  or  aortic 
diastolic,  or  double  aortic  murmur. 

The  rational  symptoms  are  : 

Fever,  prostration,  disturbed  action  of  the  heart  witli  conse- 
quent changes  in  the  circulation,  and  symptoms  due  to  embo- 
lism.    The  disturbed  heart-action  follows  one  of  two  tj'pes  : 

1.  The  heart's  action  is  violent,  tumultuous,  and  irregular; 
there  is  very  marked  venous  congestion  of  different  parts  of  the 
body. 

The  congestion  of  the  pia  mater  produces  delirium  and 
stupor. 

The  congestion  of  the  lungs  gives  labored  breathing,  and 
may  go  on  to  inflammation  and  consolidation  of  parts  of  the 
lungs. 

The  congestion  of  the  pleura  produces  hydrothorax  ;  that  of 
the  stomach,  vomiting  ;  that  of  the  liver,  enlargement  of  that 
organ  ;  that  of  the  peritoneum,  ascites  ;  that  of  the  subcutaneous 
connective  tissue,  dropsy. 

The  congestion  of  the  kidneys  is  attended  with  a  diminished 
quantity  of  urine,  which  contains  a  little  albumin  and  a  few 
casts.  If  the  urine  is  scanty  for  a  long  time  the  patients  become 
anaemic  and  develop  the  symptoms  of  chronic  uraemia. 

2.  The  heart's  action  is  feeble  and  rapid.  There  is  not  as 
much  disposition  to  venous  congestion,  but  the  patients  suffer 
from  dyspnoea,  they  are  very  feeble,  they  are  liable  to  attacks  of 
syncope. 

The  emboli  which  give  the  most  marked  symptoms  are  those 
which  become  lodged  in  the  cerebral  arteries. 

A  large  number  of  cases  of  acute  endocarditis  recover,  but 
very  few  without  permanent  changes  in  the  valves. 

In  some  the  valves,  although  rendered  insufficient,  undergo 
no  further  changes,  and  the  patients  do  well. 

In  some  the  valves,  after  remaining  unchanged  for  )^ears, 
finally  become  the  seat  of  chronic  endocarditis. 

In  some  the  acute  endocarditis  passes  into  the  chronic  form, 
and  the  patients  grow  worse  with  but  little  interruption. 

Treatment. — The  principal  objects  of  treatment  are  the  cure 
of  the  rheumatism  and  the  relief  of  the  bad  heart-action  with 
the  consequent  disturbances  of  circulation.  For  the  rheumatism 
the  most  efficient  remedies  are  the  salicylate  of  soda,  the  oil  of 
wintergreen,  the  alkalies,  antipyrine,  and  plienacetine. 


I40  THE   HEART. 

If  the  heart's  action  is  exaggerated,  tumultuous,  and  irregu- 
lar, with  excessive  venous  congestion,  we  employ  venesection, 
wet  cups  or  leeches,  purging  or  sweating.  Chloral  hydrate, 
amyl  nitrite,  opium,  and  potassium  iodide  are  often  of  much 
service. 

If  the  heart's  action  is  feeble  and  rapid  we  need  the  cardiac 
stimulants — digitalis,  convallaria,  caffeine,  and  alcohol. 

MALIGNANT    ENDOCARDITIS. 

Lesions. — Either  the  mitral,  the  aortic,  or  the  tricuspid  valve, 
the  endocardium  of  the  left  auricle,  or  of  the  right  ventricle  may 
be  inflamed.  The  inflamed  endocardium  is  covered  Avith  a 
thin  or  thick  layer  of  soft  material  composed  of  fibrin  and  micro- 
cocci, usually  the  ordinary  streptococci  and  staphylococci  of  sup- 
puration or  the  diplococcus  pneumoniae.  The  endocardium  be- 
neath is  swollen,  infiltrated  with  cells,  often  ulcerated.  If  the 
malignant  endocarditis  affects  a  heart  already  the  seat  of  chronic 
endocarditis,  the  old  lesions  persist. 

Portions  of  the  soft  matter  on  the  inflamed  endocardium  often 
become  detached  and  are  lodged  as  emboli  in  the  arteries  of  the 
brain,  lungs,  heart,  spleen,  and  kidneys.  These  emboli  are  in- 
fectious and  set  up  an  inflammation  of  the  surrounding  tissues. 
So  there  may  be  complicating  meningitis,  pericarditis,  bronchi- 
tis, pneumonia,  or  synovitis.  The  liver,  spleen,  and  kidneys  are 
swollen  and  their  cells  degenerated. 

Causes. — In  order  to  have  a  malignant  endocarditis,  it  is  neces- 
sary to  have  some  ordinary  cause  of  endocarditis  combined  with 
an  infection  by  pathogenic  bacteria.  The  bacteria  found  most 
frequently  are  the  streptococci,  staphylococci  and  diplococcus 
pneumoniae.  Such  an  endocarditis  may  attack  a  normal  heart, 
or  one  in  which  the  lesions  of  chronic  endocarditis  already  exist. 

Symptoms. — There  are  two  very  noticeable  features  about  the 
disease. 

1.  The  very  great  predominance  of  the  infectious  symptoms 
over  the  cardiac  symptoms.  Often  the  heart's  action  is  regular, 
there  are  no  disturbances  of  circulation,  not  much  of  a  murmur, 
very  little  to  call  attention  to  the  heart.  On  the  other  hand  the 
evidences  of  systemic  poisoning — the  fever,  cerebral  symptoms, 
and  prostration  are  very  marked. 

2.  When  this  form  of  endocarditis  attacks  a  heart  already  the 


THE    HEART.  141 

seat  of  chronic  endocarditis,  two  distinct  histories  become  con- 
tinuous. There  is  the  ordinary  history  of  a  chronic  endocarditis 
extending-  over  months  or  years,  and  then  at  some  particular 
time  are  added  the  symptoms  of  infection. 

Symptoms. — Tiie  disease  begins  with  chills  and  a  febrile  move- 
ment. There  is  loss  of  appetite  and  sometimes  vomiting;  the 
breathing  is  rapid.  The  heart's  action  may  not  be  very  much 
disturbed  ;  or  it  may  be  feeble,  rapid,  and  irregular.  The  tem- 
perature continues  high — 103°  F.  to  107°  F. — but  with  occasional 
rapid  falls.  Cerebral  symptoms  are  soon  developed — restlessness, 
sleeplessness,  delirium,  and  stupor.  There  is  a  heart  murmur  if 
the  endocarditis  is  sufficient  to  produce  insufficiency  or  roughen- 
ing of  the  valves.  The  urine  contains  some  albumin  ;  the  joints 
may  be  inflamed  ;  there  may  be  convulsions  or  paralyses  from 
embolism  of  the  larger  cerebral  arteries.  There  may  be  bleeding 
from  the  mucous  membranes  and  into  the  skin. 

The  patients  pass  into  a  typhoid  condition  and  die,  most  at 
the  end  of  seven  to  ten  days,  a  few  within  three  days,  some  not 
until  after  three  to  five  weeks. 

The  whole  picture  is  that  of  an  infectious  disease,  with  more 
or  less  pronounced  evidence  of  the  cardiac  lesion. 

The  diagnosis  of  malignant  endocarditis  is  a  very  difficult  one. 
The  cases  resemble  very  closely  meningitis,  general  tuberculosis, 
typhoid  fever,  and  septic  poisoning. 

Treatment. — There  seems  to  be  no  treatment  for  this  disease. 


CHRONIC    ENDOCARDITIS. 

Lesions. — The  inflammation  involves  most  frequently  the  mitral 
and  aortic  valves,  less  often  the  tricuspid  and  pulmonary  valves 
and  the  endocardium  of  the  ventricles  and  auricles.  There  are 
two  forms  of  chronic  endocarditis. 

1.  The  endocardium  is  thick,  dense  ;  there  may  be  little,  beaded 
vegetations  on  its  surface  ;  it  may  be  infiltrated  with  the  salts  of 
lime.  But  its  surface  remains  smooth,  and  thrombi  are  not 
formed  on  it.  Such  an  endocarditis  renders  the  valves  rigid,  in- 
sufficient, or  stenosed. 

2.  The  endocardium  is  thickened,  there  is  a  growth  of  cells 
producing  vegetations  and  ulcers,  the  surface  of  the  endocar- 
dium is  roughened,  and  thrombi  are  formed  on  it.     In  such  an 


142  THE   HEART. 

inflamed  endocardium  there  may  also  be  a  deposition  of  tlie  salts 
of  lime. 

When  the  valves  are  affected  by  either  of  these  forms  of  end- 
ocarditis they  are  rendered  insufficient,  or  stenosed.  Tliese 
changes  are  followed  by  dilatation  of  the  ventricles,  by  hypertro- 
phy of  their  walls,  and  by  disturbances  of  the  circulation  of  the 
blood  throughout  the  body. 

With  chronic  endocarditis  are  often  associated  myocarditis, 
endarteritis,  contraction  of  the  arteries,  emphysema,  and  chronic 
nephritis. 

Causes. — Chronic  endocarditis  may  succeed  acute  endocarditis, 
either  immediately  or  after  a  long  interval.  It  may  be  caused  by 
rheumatism,  gout,  or  syphilis.  It  very  often  is  a  primary  lesion. 
It  is  rarely  due  to  the  rupture  of  a  valve  by  external  violence. 

The  symptoms  depend  on  : 

The  endocarditis. 

The  dilatation  and  hypertrophy. 

The  character  of  the  heart's  action. 

The  presence  of  thrombi  on  the  endocardium. 

The  myocarditis. 

The  endarteritis. 

The  contraction  of  the  arteries. 

The  emphysema.     . 

The  chronic  nephritis. 

The  general  venous  congestion. 

I.  The  Endocarditis. — The  inflammation  may  last  for  months 
or  years,  cease  to  be  active,  and  no  further  changes  be  produced 
in  the  valves  ;  or  it  may  continue  slowl)'  and  with  intermissions 
up  to  the  time  of  the  patient's  death,  the  valves  becoming  more 
and  more  damaged,  and  the  inflammation  extending  to  other 
valves  ;  or  the  inflammation  may  be  more  active,  the  endocar- 
dium more  rapidly  and  profoundly  changed,  with  a  febrile  move- 
ment and  loss  of  nutrition. 

The  changes  in  the  endocardium,  due  to  the  inflammation, 
may  produce  cardiac  murmurs. 

Aortic  stenosis  gives  a  murmur  with  the  first  sound,  and  dur- 
ing the  first  silence.  The  murmur  is  loudest  at  mid-sternum, 
opposite  the  third  interspace.  It  is  transmitted  upward  and  to 
the  right.  It  may  be  heard  behind  on  the  left  side  of  the  sec- 
ond, third,  and  fourth  dorsal  vertebrae.  It  may  be  loudest  at  the 
lower  end  of  the  sternum,  or   in   the   second  interspace,  on   the 


THE    HEART.  143 

riglit  or  left  side.  There  may  be  well-marked  aortic  stenosis 
with  no  murmur. 

Aortic  insufficiency  gives  a  murmur  with  the  second  sound, 
loudest  at  mid-sternum  opposite  the  third  interspace.  It  is 
transmitted  down  the  sternum,  and  upward  to  the  right.  It 
may  be  loudest  at  the  lower  end  of  the  sternum,  in  the  left 
fourth  interspace,  or  at  the  apex.  It  is  a  very  constant  mur- 
m  u  r. 

Mitral  stenosis  gives  a  presystolic,  or  systolic  murmur,  or 
both.  The  presystolic  murmur  is  heard  just  before  the  first 
sound.  It  is  loudest  at  the  apex  and  is  usually  circumscribed. 
The  svstolic  murmur  is  loudest  at  the  apex  and  is  transmitted  to 
the  left.  The  murmurs  of  mitral  stenosis  are  very  inconstant, 
and  often  absent  altogether. 

Mitral  insufficiency  gives  a  systolic  murniur,  loudest  at  the 
apex,  and  transmitted  to  the  left.  This  murmur  is  nearly  always 
a  constant  one. 

Ventricular  murmurs  are  produced  by  roughening  of  the  ven- 
tricular endocardium,  or  thrombi  in  the  ventricles.  They  are 
systolic,  loudest  at  the  apex,  and  circumscribed.  They  are  not 
constant. 

2.  Dilatation  and  Hypertrophy  of  the  Ventricles.  —  Dilatation 
alone  of  the  ventricles  adds  to  the  dangers  of  the  endocarditis. 
Hypertrophy  alone  seems  often  to  be  of  benefit.  Hypertrophy 
and  dilatation  together,  if  not  excessively  developed,  may  also 
be  of  benefit.  A  heart  which  remains  of  normal  size,  or  which 
becomes  small  when  associated  with  advanced  valvular  changes, 
is  apt  to  act  badly. 

Aortic  stenosis  is  regularly  followed  by  dilatation  and  hyper- 
trophy, first  of  the  left  ventricle,  then  of  the  right. 

Aortic  insufficiency  is  followed  by  dilatation  and  hypertrophy 
of  the  left  ventricle. 

Mitral  stenosis  should  be  followed  by  dilatation  and  hyper- 
trophy of  the  left  auricle  and  the  right  ventricle.  But  there 
may  be  dilatation  alone  of  either  or  of  both  ventricles  ;  or  dila- 
tation and  hypertrophy  of  the  left  ventricle  ;  or  the  entire  heart 
may  be  small. 

Mitral  insufficiency  is  followed  by  dilatation  alone,  or  dilata- 
tion and  hypertrophy  of  the  left  ventricle. 

3.  The  Character  of  the  Heart's  Action. — Disturbances  of  the 
heart's   action  seem    to  depend  upon  the  changes  in  the  valves 


144  THE   HEART. 

and  walls  of  the  heart  ;  upon  contraction  of  the  arteries  ;  and 
upon  unknown  causes. 

The  heart's  action  may  be  rapid,  slow,  feeble,  forcible,  inter- 
mittent, irregular,  or  tumultuous.  The  contractions  of  the  lieart 
may  be  so  feeble  that  there  are  more  apex-beats  than  arterial 
pulsations. 

Aortic  and  mitral  stenosis,  without  contraction  of  tlie  arte- 
ries, give  a  feeble  and  irregular  pulse  ;  with  contracticjn  of  the 
arteries,  the  pulse  is  tense,  and  the  heart-action  often  laboring. 
Aortic  stenosis  may  give  more  ventricular  contractions  than 
heart-beats. 

Aortic  insufficiency  gives  an  exaggerated  heart  action,  with 
dilated  arteries,  full  of  blood,  but  soft. 

Abnormal  sensations  referred  to  the  heart  seem  to  depend 
upon  its  disturbed  action. 

There  may  be  actual  pain,  referred  to  the  heart  and  the  left 
shoulder  ;  the  pain  constant,  produced  by  exertion,  or  paroxys- 
mal. Or  there  are  feelings  of  constriction,  or  of  displacement  of 
the  heart. 

4.  Thrombi  Attached  to  the  Endoca?'diiivi.  —These  interfere  with 
the  heart's  action.  They  may  obstruct  the  orifices  of  the  heart ; 
fragments  of  them  lodged  in  the  cerebral  arteries  produce  con- 
vulsions, paralysis,  and  aphasia. 

5.  Myocarditis. — Interstitial  myocarditis,  degeneration  of  the 
heart-muscle,  and  disease  of  the  coronary  arteries  are  each  one 
capable  of  rendering  the  heart's  action  feeble  and  irregular,  of 
producing  attacks  of  angina  pectoris,  arid  of  causing  sudden 
death. 

6.  Chronic  endarteritis  affecting  many  of  the  arteries  adds  to 
the  difficulties  of  the  circulation.  If  it  involves  the  cerebral  ar- 
teries the  characteristic  symptoms  of  cerebral  endarteritis  may 
be  developed. 

7.  Pulmonary  emphysema  is  a  frequent  complication,  and  adds 
much  to  the  dangers  of  the  endocarditis. 

8.  Venous  congestion  takes  a  very  large  share  in  producing  the 
symptoms  of  chronic  endocarditis.  It  is  due  to  the  valvular 
lesions,  the  dilatation  of  the  ventricles,  the  disturbed  heart -ac- 
tion, the  contracted  arteries,  and  the  complicating  emphysema 
or  endarteritis. 

Congestion  of  the  pia  mater  produces  delirium,  stupor,  and 
convulsions. 


THE    HEART.  I45 

Congestion  of  the  lungs  produces  chronic  bronchitis,  liaemop- 
tyses,  the  pneumonia  of  heart  disease,  oedema  of  the  lungs,  and 
hydrothorax. 

Congestion  of  the  stomach  produces  pain,  gastric  dvspepsia, 
vomiting,  and  vomiting  of  blood. 

Congestion  of  the  small  intestine  produces  loss  of  flesh  and 
strength. 

The  general  congestion  of  the  body  gives  subcutaneous  dropsy 
and  dropsy  of  the  serous  cavities. 

The  kidneys  may  be  the  seat  of  chronic  congestion,  of  chronic 
degeneration,  or  of  chronic  nephritis. 

Witli  chronic  congestion  of  the  kidney  the  quantity  of  urine 
is  diminished,  its  specific  gravity  is  high,  there  is  little  or  no  al- 
bumin, the  quantity  of  urea  to  the  ounce  of  urine  is  sufficient. 
This  change  in  the  kidney  seems  to  add  but  little  to  the  symptoms. 

The  chronic  congestion,  if  protracted,  is  succeeded  by  a 
chronic  nephritis.  The  specific  gravity  of  the  urine  falls,  the 
quantity  6f  urea  is  diminished,  and  albumin  and  casts  make  their 
appearance. 

With  chronic  degeneration  of  the  kidney  the  quantity  of  the 
urine  is  diminished,  the  specific  gravity  and  the  proportion  of 
urea  are  unchanged,  there  is  a  moderate  quantity  of  albumin  and 
a  few  casts.  If  the  excretion  of  urine  is  scanty  for  a  long  time 
the  patients  may  pass  into  the  condition  of  chronic  uraemia. 

The  chronic  nephritis  is  diffuse  and  most  frequently  follows 
one  of  two  types. 

1.  There  is  an  abundant  exudation  of  serum  from  the  vessels 
of  the  kidneys.  The  urine  is  of  low  specific  gravity  and  contains 
large  quantities  of  albumin.  The  patients  are  anaemic,  dropsical, 
and  suffer  from  chronic  uraemia. 

2.  There  is  little  or  no  exudation  from  the  blood-vessels  of 
the  kidneys,  but  there  is  an  extensive  growth  of  interstitial  con- 
nective tissue.  The  urine  is  of  low  specific  gravity,  contains 
little  urea,  and  little  or  no  albumin.  The  patients  are  liable  to 
attacks  of  acute  uraemia,  with  contracted  arteries. 

Course  of  the  Disease. — The  disease  may  succeed  one  or  more 
attacks  of  acute  endocarditis,  or  it  may  be  chronic  froni  the 
outset. 

In  the  chronic  cases  the  symptoms  are  usually  not  developed 
until  the  disease  has  existed  for  some  time.  Then  first  one  or 
two  symptoms  appear  and  others  are  added  later. 


146  THE   HEART. 

The  first  symptom  may  be  : 

Dyspnoea  on  exertion. 

Anaemia  and  emaciation. 

Cough  and  expectoration. 

Cardiac  palpitation  and  pain. 

Stomach  symptoms. 

Dropsy. 

Contraction  of  the  arteries. 

It  sometimes  happens  that  the  patients  go  on  for  a  long  time 
with  an  endocarditis,  but  without  symptoms.  Then  suddenly, 
with  a  pericarditis,  a  pleurisy,  a  bronchitis,  or  without  discover- 
able cause,  they  develop  a  m.ost  distressing  and  urgent  dyspnoea 
with  contracted  arteries.  This  dyspnoea  continues  and  the  pa- 
tients die  within  a  few  days  or  weeks. 

The  endocarditis  may  stop  at  any  time.  It  may  go  on  slowly, 
or  quickly  ;  it  may  be  complicated  by  the  diseases  already 
mentioned. 

The  bad  cases  die  with  dyspnoea  ;  or  feeble  and  emaciated  ; 
or  with  dropsy  ;  or  with  cerebral  symptoms  ;  or  they  die  suddenly. 

The  prognosis  depends  upon  : 

The  extent  and  activity  of  the  endocarditis. 

The  condition  of  the  ventricles. 

The  character  of  the  heart's  action. 

The  presence  or  absence  of  contraction  of  the  arteries. 

Treatment. — The  principal  indications  for  treatment  are  to 
check  the  progress  of  the  endocarditis,  to  regulate  the  action  of 
the  heart  and  the  condition  of  the  arteries,  and  to  alleviate 
symptoms. 

To  check  the  progress  of  the  endocarditis  we  put  the  patient 
on  a  diet  of  fats,  meat,  fruits,  and  vegetables  ;  we  prohibit  the 
use  of  alcohol  and  tobacco,  and  we  insist  on  a  life  passed  in  the 
open  air. 

To  regulate  the  action  of  the  heart  and  the  condition  of  the 
arteries.  If  the  arteries  are  contracted  we  employ  nitrite  of 
amvl,  nitroglycerine,  potassium  iodide,  chloral  hydrate,  or  opium. 

If  the  heart's  action  is  feeble  we  use  digitalis,  strophanthus, 
caffeine,  or  convallaria.  If  the  heart's  action  is  too  forcible  we 
use  continuous  cold  over  the  heart,  a  nitric-acid  issue,  aconite, 
veratrum  viride,  or  barium  chloride. 

With  aortic,  or  mitral,  stenosis  and  a  feeble  heart  it  may  be 
necessary  to  confine  the  patients  to  bed. 


THE   HEART.  I47 

With  many  forms  of  endocarditis  the  patients  do  best  if  they 
are  allowed  to  follow  their  ordinary  mode  of  life,  avoiding  sud- 
den and  violent  exertion. 

In  a  certain  number  of  cases  very  excellent  results  are  ob- 
tained by  regular  hill-climbing. 

CHRONIC    ENDOCARDITIS    WITH    FEVER. 

In  the  course  of  any  chronic  endocarditis  there  may  be  loss  of 
nutrition,  and  on  some  days  a  rise  of  temperature.  But  there 
are  some  cases  of  chronic  endocarditis  in  which  the  rise  of 
temperature  and  the  loss  of  nutrition  are  the  prominent  symp- 
toms, while  there  is  but  little  disturbance  of  the  circulation. 
The  behavior  of  the  cases  is  such  as  to  remind  one  of  malig- 
nant endocarditis  and  to  give  the  impression  that  the  symptoms 
depend  rather  on  bacterial  poisoning  than  on  the  cardiac  lesion. 

Lesions. — Either  the  aortic  or  the  mitral  valves  are  affected. 
There  is  a  growth  of  cells  in  the  endocardium  with  more  or  less 
ulceration  and  the  formation  of  vegetations.  The  bacteriology 
has  not  been  worked  up. 

Symptoms. — The  most  noticeable  symptom  is  the  fever.  In 
most  of  the  cases  there  is  every  day  an  afternoon  temperature  of 
from  100"  to  104°  F.,  while  tlie  morning  temperature  is  from  97° 
to  99°  F.  With  the  fever  there  may  be  chilliness  and  sweating. 
Less  frequently  the  fever  comes  on  every  other  day.  The  whole 
behavior  of  the  fever  is  such  as  to  make  one  think  of  malarial 
poisoning.  It  is  said  that  in  some  cases  the  endorcarditis  is 
preceded  by  a  true  malarial  fever. 

The  patients  are  at  first  not  confined  to  bed,  but  gradually 
lose  flesh  and  strength.  There  is  a  cardiac  murmur,  but  no 
other  cardiac  symptoms.  There  are  often,  however,  days  and 
weeks  of  considerable  improvement  and  less  fever.  But  then 
the  fever  comes  on  again  and  the  patients  get  worse.  Thev  con- 
tinue in  this  way  for  from  six  to  twelve  months,  and  finally  die 
in  a  condition  of  extreme  feebleness  and  emaciation. 

Hypertrophy  and  Dilatation  of    the    Heart  without  Endo- 
carditis. 

I.   From  excessive  and  prolonged  muscular  exertion. 
The  left  ventricle  alone,  or  both  ventricles,  are  hypertrophied 
or  dilated,  or  both  dilated  and  hypertrophied. 


148  THE   HEART. 

To  produce  these  changes  in  the  heart  the  muscular  exertion 
must  be  excessive  and  prolonged,  so  we  find  them  most  frequent- 
ly in  soldiers,  athletes,  and  laborers. 

In  the  milder  cases  there  is  only  hypertrophy  of  the  left  ven- 
tricle. The  patient  has  the  feelings  of  pain,  constriction,  or  dis- 
placement of  the  heart,  with  rapid  heart-action. 

These  patients  usually  do  well.  It  is  only  necessary  to  make 
them  lead  a  resrular  life  and  sometimes  to  talce  digfitalis. 

In  the  more  severe  cases  there  is  dilatation  alone,  or  dilatation 
with  hypertrophy.  There  are  pains  over  the  heart,  rapid  and 
feeble  heart-action,  dyspnoea  on  exertion,  and  loss  of  flesh  and 
strength.  These  cases  are  always  serious,  and  not  all  of  them 
recover. 

It  is  necessary  to  keep  the  patients  in  bed,  and  to  use  cardiac 
stimulants. 

II.  From  disease  of  the  lungs. 

Emphysema,  chronic  phthisis,  interstitial  pneumonia,  pleurisy, 
and  deformities  of  the  chest  may  produce  dilatation,  first  of  the 
right  ventricle,  and  afterward  of  the  left. 

III.  Exophthalmic  goitre,  or  prolonged  palpitation  of  the 
heart,  may  be  followed  by  hypertrophy  of  the  left  ventricle. 

IV.  Acute  or  chronic  nephritis,  chronic  inflammation  of  the 
aortic  system  of  arteries,  and  congenital  narrowing  of  the  aorta 
may  produce  hypertrophy  of  the  left  ventricle. 

V.  Simple  anaemia  may  be  attended  with  temporary  dilatation 
and  hA'pertrophy  of  the  left  ventricle,  or  of  the  right  auricle  and 
ventricle. 

VI.  There  is  an  important  group  of  cases  of  dilatation  of  the 
ventricles  without  hypertrophy,  of  which  the  causa,tion  is  very 
obscure. 

Usually  both  ventricles  are  dilated,  but  sometimes  only  the 
left.  The  valves  are  normal,  but  their  orifices  may  be  so  large 
that  they  are  insufficient.  The  walls  of  the  ventricles  are  nor- 
mal, or  the  muscular  fibres  are  degenerated,  or  there  is  a  growth 
of  cells  between  the  fibres.  Thrombi  may  be  formed  in  the  cav- 
ities of  the  ventricles.  Venous  congestion  of  the  viscera  is  soon 
established,  dropsy  somewhat  later. 

Of  the  causes  of  this  heart-lesion  we  are  ignorant.  It  is  often 
enough  developed  in  young  and  healthy  adults.  In  some  cases 
there  is  a  distinct  history  of  sudden  muscular  exertion  ;  in  others, 
no  excitino:  cause  can  be  discovered. 


THE    HEART,  I49 

In  the  more  acute  cases  the  invasion  of  the  symptoms  is  sud- 
den. 

The  patients  complain  of  pain  in  tlie  epigastrium,  they  become 
unconscious,  and  they  vomit  ;  or  the  first  symptom  is  urgent  car- 
diac dyspnoea.  After  this  the  heart's  action  is  rapid,  irregular, 
and  feeble.  The  physical  signs  are  those  of  dilatation  of  the 
heart.  There  is  constant  and  distressing  dyspnoea,  there  may  be 
cough  and  haemoptyses,  the  patients  lose  flesh  and  strength,  and 
die  at  the  end  of  a  few  weeks. 

In  the  more  clironic  cases  the  invasion  is  less  sudden  and 
decided.  The  patients  suffer  from  rapid,  feeble,  and  irregular 
heart-action,  dyspnoea,  cough,  and  haemoptyses,  marked  dropsy, 
and  loss  of  flesh  and  strength.  They  may  live  for  several 
montlis. 

The  treatment  of  these  cases  is  eminently  unsatisfactory.  We 
are  unable  to  improve  the  action  of  the  heart,  and  the  best  that 
we  can  do  is  to  palliate  the  patient's  sufferings  with  opium. 

The  Fatty  Heart. 

i.  There  is  an  accumulation  of  fat  beneath  the  pericardium. 
This  occurs  in  persons  wlio  also  have  accumulations  of  fat  in 
other  parts  of  tiie  body. 

The  heart's  action  is  often  feeble,  and  there  is  dyspnoea  on 
exertion.  It  is  difficult  to  tell  whether  the  cardiac  symptoms  are 
due  to  the  fat  on  the  heart  or  to  the  general  condition  of  the 
patient. 

The  indications  for  treatment  are  by  a  regulated  diet  and  s_ys- 
tematic  exercise  to  remove  the  fat. 

2.  There  is  a  fatty  degeneration  of  the  muscular  fibres  of  the 
walls  of  the  heart. 

The  heart  remains  of  its  normal  size,  or  becomes  somewhat 
smaller.  Its  walls  are  s  'ft  and  lighter  colored.  The  degenera- 
tion may  involve  the  walls  of  both  ventricles,  or  of  one,  or  of  part 
of  one.  The  degeneration  may  advance  so  far  at  some  one  point 
that  the  wall  of  tlie  ventricle  will  be  ruptured. 

Causes. — This  change  in  the  heart  may  be  secondary  to  pro- 
found anaemia,  to  long  and  wasting  diseases,  to  the  severe  infec- 
tious diseases,  and  to  poisoning  by  phosphorus.  It  occurs  also 
as  a  primary  disease,  and  is  then  especially  common  in  males 
between  the  ages  of  forty  and  seventy. 


ISO  THE     HEART. 

Symptoms. — Physical  signs  :  The  heart  is  of  normal  size,  or 
diminished.  The  impulse  is  feeble  ;  the  first  sound  is  short  and 
feeble  ;  the  action  may  be  regular,  irregular,  fast,  or  slow.  The 
systolic  murmur  at  the  apex,  or  at  the  second  left  interspace, 
wiiich  occurs  without  valvular  lesions,  may  be  present. 

There  may  be  pain,  referred  to  the  heart,  either  continuous 
or  spasmodic  ;  or  attacks  of  angina  pectoris. 

There  may  be  attacks  of  syncope,  dyspnoea  on  exertion,  or 
constant  dyspnoea.  Cerebral  symptoms  :  Vertigo,  convulsions, 
loss  of  consciousness,  or  coma  may  be  developed.  There  may 
be  gradual  loss  of  flesh  and  strength.  Dropsy  is  not  a  frequent 
symptom. 

Some  of  the  patients  never  give  any  symptoms  of  their  car- 
diac lesion,  and  die  of  some  other  disease. 

Some  give  no  symptoms  until  they  have  a  fatal  attack  of  an- 
gina, of  syncope,  of  coma,  or  of  rupture  of  the  heart. 

Some  give  the  characteristic  symptoms  of  the  disease  for 
months  or  years. 

Treatment. — The  best  that  can  be  done  is  the  regulation  of  the 
diet  and  mode  of  life,  and  the  use  of  cardiac  stimulants. 

Rupture  of  the  Heart. 

Lesions. — Ruptures  of  the  heart  are  most  comnjon  in  the  ante- 
rior wall  of  the  left  ventricle  near  the  apex.  They  also  occur  in 
the  wall  of  the  right  ventricle,  the  right  auricle,  the  septum  be- 
tween the  ventricles  and  the  papillary  muscles.  The  rupture  is 
small,  direct,  or  indirect.  The  rupture  is  due  to  fatty  degenera- 
tion of  the  muscle,  or  to  occlusion  of  one  of  the  branches  of  the 
coronary  artery. 

Symptoms. — The  rupture  may  occur  during  exertion,  or  while 
the  patient  is  perfectly  quiet. 

If  the  rupture  is  direct,  death  is  almost  instantaneous.  If  it 
is  indirect,  the  patients  may  live  for  hours  or  days.  They  have 
sudden  pain  in  the  heart,  vomiting,  dyspnoea,  prostration,  irregu- 
lar and  feeble  heart-action. 

Chronic    Myocarditis. 

Definition. — A  chronic  productive  inflammation  of  the  con- 
nective-tissue stroma  of  the  heart,  resulting  in  a  production  of 
new  connective  tissue  and  degeneration  of  the  muscular  fibres. 


THE    HEART,  151 

Lesions. — The  wall  of  the  left  ventricle,  the  septum  between 
the  ventricles,  and  the  papillary  muscles  are  the  portions  of  the 
heart  most  frequently  involved.  The  inflammation  may  be  dif- 
fuse, involving  most  of  the  wall  of  the  left  ventricle,  or  circum- 
scribed, involving  only  a  part  of  it.  The  changes  are  usually 
most  marked  at  the  apex  of  the  left  ventricle.  The  coronary  ar- 
teries and  the  arteries  in  other  parts  of  the  body  regularly  show 
the  lesions  of  chronic  arteritis.  The  left  ventricle  may  be  di- 
lated or  hypertrophied.  There  may  be  thrombi  in  the  left  ven- 
tricle. In  the  portion  of  the  heart-wall  affected  by  the  inflam- 
mation there  are  found  :  a  new  growth  of  connective  tissue, 
sometimes  an  infiltration  with  pus-cells,  and  degeneration,  or 
atrophy,  of  the  muscular  fibres. 

The  inflamed  portion  of  the  heart-wall  may  rupture,  or  may 
be  pouched  out  so  as  to  form  an  aneurism. 

Etiology. — In  some  cases  the  myocarditis  seems  to  be  second- 
ary to  occlusion  of  the  coronary  arteries,  or  to  an  adherent  peri- 
cardium. In  other  cases  it  is  due  to  the  same  causes  which 
produce  chronic  productive  inflammations  in  other  parts  of  the 
body. 

Symptoms. — The  physical  signs  consist  in  the  evidences  of 
dilatation  or  hypertrophy,  and  the  extremely  irregular  action  of 
the  heart. 

It  is  possible  for  the  disease  to  exist  without  subjective  symp- 
toms, but  very  often  they  are  present. 

There  may  be  the  consciousness  of  irregular  heart-action, 
pain,  feelings  of  constriction,  or  attacks  of  true  or  false  angina 
pectoris.  The  heart's  action  is  irregular,  either  too  rapid  or  too 
slow. 

There  may  be  attacks  of  syncope  or  of  coma,  or  the  mental 
faculties  may  be  disturbed. 

Dyspnoea  may  be  due  to  the  impaired  heart-action,  to  the 
complicating  arteritis,  or  to  attacks  of  contraction  of  the  arteries. 

Venous  congestion  of  the  liver,  stomach,  intestines,  and  kid- 
neys may  be  established,  with  the  accompanying  loss  of  nutrition. 
Dropsy  is  not  common. 

The  patients  may  die  suddenly. 

Treatment. — The  patients  regularly  get  worse  from  year  to  year 
in  spite  of  treatment.  At  first  the  cardiac  stimulants  may 
alleviate  symptoms,  but  later  in  the  disease  they  are  of  no  service 
and  opium  is  the  only  drug  that  gives  any  relief. 


152  THE   HEART. 

The  Neuroses  of  the  Heart. 

THE     irregular    HEART. 

There  is  a  large  class  of  cases  of  disturbance  of  the  action  of 
tlie  heart  without  structural  disease  for  which  we  have  no  good 
name,  and  which  we  cannot  as  yet  subdivide  in  a  satisfactory 
manner. 

The  heart's  action  may  be  too  rapid,  or  irregular,  or  intermit- 
tent, or  exaggerated,  or  too  slow.  These  changes  in  the  heart's 
action  either  occur  in  paroxysms,  or  continue  for  long  periods  ; 
they  only  occur  after  exciting  causes,  or  continue  when  no  cause 
can  be  discovered. 

Such  an  irregular  heart-action  is  accompanied  with  conscious- 
ness of  the  lieart's  action  ;  abnormal  cardiac  sensations  ;  feelings 
of  constriction,  displacement,  dropping  of  blood,  etc.  ;  more  or 
less  mental  anxiety  ;  vertigo,  headache,  fulness  of  the  head,  syn- 
cope, and  sleeplessness  ;  loss  of  flesh  and  strength  ;  disturbances 
of  digestion. 

Many  of  the  cases  are  mild  and  easily  relieved,  but  others 
give  serious  symptoms,  and  are  but  little  benefited  by  treatment. 

The  diagnosis  of  many  of  the  cases  is  easy  ;  but  it  may  be 
difficult  to  distinguish  this  condition  from  exophthalmic  goitre, 
chronic  myocarditis,  disease  of  the  coronary  arteries,  the  fatty 
heart,  or  stenosis  of  one  of  the  valves  without  a  murmur. 

The  physical  signs  are  tlie  change  in  tlie  action  of  the  heart, 
and  sometimes  a  murmur  at  tlie  second  left  space,  or  at  the  apex. 

To  the  cases  in  which  the  heart's  action  is  exaggerated  the 
name  of  "Palpitation"  is  often  given.  It  can  be  seen  and  felt 
that  the  contractions  of  the  ventricles  are  unnaturally  forcible. 
The  mere  consciousness  of  the  heart's  action  is  a  discomfort,  and 
in  addition  there  may  be  the  feelings  of  pain  or  constriction. 

The  name  of  "Tachycardia"  is  given  to  the  cases  in  which 
the  heart-action  is  too  rapid,  whether  forcible  or  feeble.  Exclud- 
ing cases  of  organic  disease  of  the  heart  and  of  exophthalmic 
goitre,  there  remains  a  class  of  cases  in  which  the  rapid  heart- 
action  seems  to  be  a  neurosis.  The  tachycardia  occurs  in  par- 
oxysms, or  is  continuous  for  long  periods.  The  patients  may 
have  some  uncomfortable  feelings  about  the  heart,  but  the  most 
noticeable  thing  about  them  is  their  loss  of  nutrition.     Generally 


THE    HEART.  153 

speaking  these  patients  do  not  improve  until  tlie  heart  beats 
more  slowly. 

The  names  of  "  Cardiac  Asthenia,"  or  "  Heart  Exhaustion,"  are 
given  to  the  cases  in  which  the  heart's  action  is  too  feeble,  al- 
though there  is  no  disease  of  the  heart.  The  patients  are  often 
obliged  to  stay  in  bed.  If  they  sit  up  they  feel  faint,  or  lose 
consciousness.  The  heart's  action  is  feeble,  the  pulse  small  and 
compressible,  and  generally  increased  in  frequency.  There  may 
be  uncomfortable  feelings  about  the  heart,  but  no  pain.  The 
skin  is  cold,  the  appetite  poor,  the  bowels  constipated.  The  pa- 
tients are  sleepless,  nervous,  and  depressed.  In  most  of  these 
cases  the  cardiac  symptoms  are  only  the  most  prominent  symp- 
toms of  the  condition  of  neurasthenia. 

Treatment. — We  first  try  to  find  out  if  there  is  an  exciting 
cause  for  the  disturbed  heart-action  which  can  be  removed  or 
treated.  Such  causes  are  tobacco,  coffee,  tea,  disturbances  of 
digestion,  anaemia,  and  hysteria. 

If  such  an  exciting  cause  can  be  discovered  and  be  removed, 
or  successfully  treated,  we  may  be  able  to  cure  the  cardiac  dis, 
turbance  ;  but  it  may  well  be  that  all  attempts  at  treatment  on 
these  lines  turn  out  to  be  useless,  and  tliat  we  have  to  try  to 
directly  influence  the  action  of  the  heart.  For  this  purpose  we 
employ  digitalis,  convallaria,  caffein,  strophanthus,  potassium 
iodide,  aconite,  belladonna,  or  opium,  separately,  or  combined  in 
various  ways. 

The  general  management  of  these  patients  is  a  matter  of  much 
importance.  Some  of  them  need  rest  in  bed,  others  require 
graduated  exercise.  Much  can  be  done  by  the  careful  use  of  hot 
and  cold  baths,  and  of  massage.  The  diet  must  be  so  regulated 
that  the  patients  get  enough  to  eat.  All  functional  disturbances 
of  the  stomach  and  bowels  are  to  be  corrected. 

Angina  Pectoris. 

A  disease  characterized  by  pain,  oppression,  and  a  sense  of 
impending  death. 

It  is  agreed  that  the  disease  is  a  neurosis,  although  organic 
changes  of  the  heart  or  aorta  may  be  present.  It  is  also  recog- 
nized that  there  are  two  types  of  the  disease,  one  with  contraction 
of  the  arteries,  and  one  with  irregular  heart-action. 

Lesions. — While  in  some  of   the  fatal  cases  of  angina  pectoris 


154  THE   HEART. 

no  lesions  of  the  heart  or  arteries  are  found,  yet  in  a  still  larger 
number  such  lesions  exist.  Inflammation  of  tiie  arch  of  the  aorta, 
of  the  coronary  arteries,  or  of  the  endocardium  ;  degeneration 
of  the  wall  of  the  heart ;  and  changes  in  the  cardiac  plexus  of 
nerves  have  been  described. 

Causes. — The  disease  is  most  common  in  persons  over  fifty 
years  of  age.  It  is  much  more  frequent  in  males  than  in  females. 
The  attacks  may  be  brought  on  by  bodily  or  mental  exertion. 
Concerning  the  real  causation  of  the  disease  we  are  still  ignorant. 

SymptoDis. — I.  PaiOtf  "Without  pain  the  complaint  does  not 
exist."  The  pain  is  referred  to  the  precordial  part  of  the  lower 
sternal  legion,  exceptionally  to  the  middle  or  upper  sternal  re- 
gion ;  with  the  pain  there  may  be  tenderness  on  pressure.  The 
pain  radiates  to  the  mid-dorsal  spine,  to  the  left  or  to  both  sides 
of  the  neck  and  occiput,  to  the  left  shoulder  and  arm,  to  both 
arms,  rarely  to  the  right  arm  alone,  to  the  left  leg,  or  to  both 
arms  and  the  left  leg.  With  the  pain  there  may  be  feelings  of 
numbness  and  tingling.  The  pain  is  severe  and  occurs  in  parox- 
ysms, which  last  for  minutes  or  hours. 

2.  There  is  a  feeling  of  cardiac  oppression  and  a  sense  of  im- 
pending death  which  produces  a  profound  impression  on  the 
patient. 

3.  The  pulse  varies  with  the  character  of  the  attack,  and  with 
the  condition  of  the  heart.  During  the  paroxysms  it  is  either  a 
high-tension  pulse,  or  a  feeble  and  irregular  pulse. 

4.  The  breathing  also  varies  in  the  different  cases.  There 
may  be  real  dyspnoea  with  cyanosis,  or  only  a  feeling  of  dyspnoea, 
or  nearly  natural  breatliing. 

5.  Tlae  alimentary  canal.  There  may  be  violent  and  con- 
tinued eructations  of  gas,  or  vomiting. 

The  mind  remains  clear;  there  may  be  slight,  or  severe  gen- 
eral convulsions  ;  the  patients  may  lose  consciousness,  or  they 
may  have  vertigo. 

The  expression  of  the  face  is  anxious,  the  skin  is  cold  and 
often  bathed  in  perspiration. 

The  attacks  usually  come  on  suddenly  and  without  warning. 
They  may,  however,  be  preceded  by  abnormal  cardiac  sensations, 
or  be  excited  by  certain  muscular  movements,  or  occur  at  regu- 
lar intervals. 

Each  attack  may  last  for  a  few  minutes,  or  for  several  hours. 
A  patient  may  have  only  a  single  attack,  from  which  he  recovers, 


THE    HEART.  155 

or  during  which  he  dies.  He  may  have  a  number  of  attacks, 
any  one  of  which  may  prove  fatal  ;  or  after  a  number  of  attaclcs 
there  may  be  no  further  recurrence. 

The  prognosis  of  the  disease  is  very  serious,  but  yet  there  are 
a  considerable  number  of  persons  who  suffer  from  one  or  more 
attacks  and  entirely  recover. 

Treatment. — If  tlie  attacks  are  accompanied  witii  contraction 
of  the  arteries  and  a  pulse  of  high  tension  they  can  often  be  re- 
lieved by  inhalations  of  the  nitrite  of  amyl,  subcutaneous  injec- 
tions of  morphine,  or  of  nitro-glycerine. 

If  they  are  accompanied  by  a  feeble  and  irregular  pulse  with- 
out contraction  of  the  arteries  w^e  employ  subcutaneous  injections 
of  digitaline  and  of  whiskey. 

Between  the  attacks  any  existing  disease  of  the  heart  may 
require  treatment. 

PSEUDO-ANGINA    PECTORIS. 

We  use  this  name  to  designate  a  somewhat  irregular  group  of 
cases,  which  present  the  common  feature  of  attacks  of  disturb- 
ance of  the  action  of  the  heart. 

Lesions. — There  may  be  chronic  inflammation  of  the  coronary 
arteries,  fatty  degeneration  of  the  heart,  inflammation  of  the 
arch  of  the  aorta,  or  no  discoverable  lesion. 

Symptoms. — Pain  may  be  absent  altogether.  When  present  it 
is  not  as  severe  as  the  pain  of  true  angina,  but  is  referred  to  the 
same  regions. 

The  patients  may  be  much  alarmed  about  themselves,  but  do 
not  have  the  feeling  of  impending  death. 

The  heart's  action  is  feeble  and  irregular,  although  sometimes 
it  may  seem  to  be  exaggerated. 

The  breathing  may  be  hurried  and  labored.  There  may  be 
vomiting  and  pain  in  the  stomach. 

The  attacks  come  on  suddenly,  they  last  for  minutes,  days,  or 
weeks.     In  the  longer  attacks  the  symptoms  are  not  continuous. 

The  patient  may  die  in  any  of  the  attacks,  or  after  one  or 
more  such  attacks  there  may  be  no  further  recurrence. 

Treatment. — During  the  attacks  we  use  cardiac  stimulants; 
between  the  attacks  we  try  to  improve  the  general  health. 


156  THE   HEART. 


Exophthalmic  Goitre. 

Basedow's  disease.     Graves's  disease. 

The  cases  are  characterized  by  rapid  heart-action,  enlarge- 
ment of  the  thyroid  gland,  and  protrusion  of  the  eyeballs. 

Lesions. — After  death  the  thyroid  gland  is  found  simply  hyper- 
trophied,  there  is  nothing  in  the  orbits,  the  left  ventricle  of  the 
heart  may  be  hypertrophied.  In  a  few  cases  in  the  ganglia  of 
the  cervical  sympathetic  there  have  been  found  degeneration  of 
the  nerve-cells  and  a  new  growth  of  connective  tissue. 

Causes. — The  disease  is  much  more  common  in  women  than 
in  men,  and  especially  during  earlv  adult  life. 

Fright,  or  severe  mental  shock,  or  over-fatigue  are  believed 
sometimes  to  act  as  causes.  Rheumatism  occurs  as  an  antecedent 
condition  in  a  number  of  cases.  The  association  of  the  disease 
with  other  nervous  disorders,  such  as  epilepsy,  hysteria,  chorea, 
diabetes,  and  insanity  has  often  been  noticed.  In  women,  anae- 
mia often  precedes  the  disease.  Tliere  is,  in  some  families,  an 
hereditary  predisposition. 

Sympto77is. — The  symptoms  are  usually  developed  slowly  and 
gradually,  but  exceptionally  are  well  marked  witliin  a  few  days. 

There  are  three  cardinal  svmptoms  :  a  rapid  lieart-action, 
goitre,  and  exophthalmos.  The  rapid  heart-action  is  the  most 
constant  symptom,  the  most  important,  and  the  one  first  devel- 
oped. The  heart's  action  is  rapid,  regular,  forcible,  and  after  a 
time  attended  with  hypertrophy  of  the  left  ventricle. 

The  enlargement  of  tlie  thyroid  gland  follows  the  rapid  heart- 
action  ;  it  is  usually,  but  not  always  present. 

The  exophthalmos  is  the  least  constant  of  the  three  symp- 
toms, and  the  last  to  be  de -eloped. 

Besides  the  three  characteristic  symptoms  of  the  disease,  there 
may  be  others. 

There  may  be  tremor  affecting  the  muscles  of  the  whole  body, 
or  only  those  of  the  arms.  It  is  a  tremor  like  that  which  is  no- 
ticed when  the  muscles  are  over-fatigued.  It  is  more  obvious 
when  the  patient  is  flurried,  and  sometimes  may  be  noticed  only 
under  such  conditions.  It  is  more  perceptible  when  the  patient 
is  sitting  up  than  when  lying  down.  It  only  interferes  with  the 
more  delicate  movements  of  the  hands,  such  as  writing  or  sew- 
inof. 


TflE    ARTERIES.  157 

There  may  be  painful  c;ranips  of  some  of  the  muscles,  espe- 
cially at  night. 

Occasionally  there  are  slight  and  temporary  elevations  of 
temperature. 

Sweating"  is  frequent  and  sometimes  excessive. 

There  may  be  a  brown  pigmentation  of  the  skin  of  the  face 
and  of  other  parts  of  the  body. 

Anaemia  is  very  frequently  present,  especially  in  young 
women. 

In  the  severe  cases  tliere  is  well-marked  loss  of  flesh  and 
strength. 

Many  of  the  patients  become  nervous  and  irritable,  hypo- 
chondriacal, or  hysterical.     Some  become  fairly  insane. 

Tlie  course  of  the  disease  is  usually  protracted  for  years  ;  but 
cases  are  reported  which  have  lasted  only  a  few  months,  or  days. 

Some  of  the  cases  recover  altogether,  some  only  in  part. 
Death  is  due  to  some  intercurrent  disease,  to  loss  of  nutrition,  to 
pressure  on  the  trachea  by  the  thyroid  tumor,  to  syncope,  or  to 
attacks  of  dyspnoea. 

Tj-eatment. — The  indications  are :  To  improve  the  general 
health,  to  cure  the  anaemia,  and  to  regulate  the  action  of  the  heart. 
For  the  heart-action  digitalis,  strophanthus,  belladonna,  or  aco- 
nite are  given,  and  either  the  galvanic  or  faradic  current  may  be 
applied  to  the  neck. 

Good  results  are  reported  after  removal  of  the  thyroid  gland. 

The  Arteries, 
chronic  arteritis. 

Synonyms. — Arterio-capillary  fibrosis,  arterio-sclerosis. 

Definition. — A  chronic  productive  inflammation  of  the  walls  of 
the  arteries,  which  involves  principally  their  inner  and  middle 
coats,  and  is  often  accompanied  by  degeneration. 

Lesions. — This  form  of  inflammation  occurs  most  frequently  in 
the  aortic  system  of  arteries,  but  it  is  also  seen  in  the  branches 
of  the  pulmonary  artery.  Only  a  part  of  the  aorta  is  involved, 
or  the  whole  of  the  aorta,  or  the  aorta  with  most  of  its  branches, 
or  the  arteries  of  some  particular  part  of  the  body. 

There  is  often  chronic  productive  inflammation  of  one  or 
more  of  the  viscera. 


158  THE   ARTERIES. 

Causes. — It  is  evident  that  these  morbid  changes  are  caused 
by  lead-poisoning,  alcohol,  gout,  and  syphilis  ;  that  the  disposi- 
tion to  them  is  hereditary  in  some  families  ;  tliat  they  constitute 
one  oi^  the  regular  senile  changes  ;  that  tiiey  are  often  associated 
with  chronic  diseases  of  the  viscera  ;  that  tlie  patients  can  be  un- 
conscious of  their  existence,  and  that,  on  the  other  hand,  they 
can  cause  most  distressing  symptoms,  and  even  deatli.  CIn-onic 
arteritis  is  seen  so  often  in  persons  over  fifty  years  of  age,  in  fact 
but  few  such  people  have  normal  arteries,  that  we  are  apt  to  for- 
get that  it  is  also  to  be  seen  in  adults  and  children. 

Thoma  and  others  beli-ve  that  the  changes  in  the  walls  of  the 
arteries  are  due  to  slowing  of  the  blood-current.  They  teach 
that  : 

1.  Every  long-continued  slowing  of  the  blood-current  causes 
contraction  of  the  middle  coat  of  thi  aorta,  ?ind,  if  this  is  not  suf- 
ficient to  accelerate  the  blood-current,  to  a  growth  of  connective 
tissue  in  the  intima. 

2.  Primary  diffuse  and  nodular  arterio-sclerosis  depends  upon 
a  weakening  of  the  wall  of  the  blood  vessel  due  to  constitutional 
conditions.  This  is  followed  by  dilatation  of  the  vessel,  slowing 
of  the  blood-stream,  and  then  the  growth  of  connective  tissue  in 
the  intima. 

3.  Secondary  arterio-sclerosis  is  caused  by  slowing  of  the 
blood-current  produced  by  changes  of  the  circulation  in  the  ca- 
pillary vessels. 

It  appears  to  me  that  the  most  practical  way  to  look  at  all 
these  changes  in  the  arteries  is  to  consider  them  the  results  of  a 
combination  of  chronic  productive  inflammation  and  degenera- 
tion occurring  in  connective  tissue.  We  shall  then  think  of  the 
arteries  as  we  do  of  the  endocardium,  or  the  liver,  or  the  kidneys, 
as  a  definite  part  of  the  body  liable  to  become  the  seat  of  chronic 
inflammation  from  the  same  causes  as  those  which  produce  sim- 
ilar changes  in  other  parts  of  the  body. 

Lesions  :  i.  The  Small  Arteries. — a.  The  simplest  change  in 
the  small  arteries  is  an  increase  in  the  size  and  number  of  the 
endothelial  cells.  This  is  best  seen  in  the  arteries  in  miliary  tu- 
bercles and  in  the  small  gummata. 

b.  There  is  a  growth  of  new  connective  tissue  from  the  endo- 
thelium, which  encroaches  upon  the  lumen  of  the  artery  and  fi- 
nally occludes  it.  The  growth  forms  a  ring  on  the  inside  of  the 
intima,  thicker  in  some  places  than  at  others. 


THE    ARTERIES.  I  59 

c.  There  is  a  thickening  of  the  inner  coat  beneath  the  endo- 
thelium. The  lumen  of  the  artery  is  irregularly  narrowed,  while 
in  other  places  the  wall  of  the  artery  is  thinned.  Besides  the 
thickening  of  the  inner  coat,  the  middle  and  outer  coats  may  also 
be  thickened. 

d.  The  whole  wall  of  the  artery  is  thickened  and  replaced  by 
dense  connective  tissue. 

2.  The  Lar-ge  Arteries. — In  the  large  arteries  altogether  the 
most  frequent  change  is  the  thickening  of  the  intima.  This  is 
often  present  in  arteries  which  look  normal  to  the  naked  eye. 
Besides  the  thickening  of  the  intima  there  is  often,  in  addition,  a 
thickening  of  the  middle  and  outer  coats,  or  a  replacement  of 
the  muscular  coat  by  connective  tissue.  When  all  the  coats  are 
thickened  in  this  way,  the  arteries  often  become  elongated  and 
tortuous.  Occasionally  there  are  areas  of  degeneration  in  the 
thickened  wall  of  the  artery,  or  even  infiltration  with  the  salts  of 
lime. 

3.  The  Aorta. — The  changes  in  the  aorta  differ  from  those  in 
the  arteries  by  reason  of  the  combination  of  degeneration  and 
necrosis  with  the  growth  of  new  tissue  due  to  the  chronic  inflam- 
mation, by  the  frequency  of  calcification,  and  by  the  liability  of 
the  outer  coat  to  purulent  infiltration.  We  find,  therefore,  in 
the  aorta  : 

a.  Simple  thickening  of  the  inner  coat  by  new  connective 
tissue. 

b.  Degeneration  and  softening  of  the  inner  and  middle  coats. 

c.  Calcification  of  the  inner  and  middle  coats. 

d.  Infiltration  of  the  outer  and  middle  coat  with  pus-cells. 

e.  Thinning  and  atrophy  of  the  inner  and  middle  coats. 

f.  The  formation  of  thrombi  on  the  roughened  surface  of 
the  inner  coat. 

Symptoms. — It  must  be  admitted  that  we  find  the  lesions  of 
chronic  arteritis  far  advanced  in  persons  who  have  never  given 
symptoms  referable  to  the  arteries.  It  must  also  be  admitted  that 
chronic  disease  of  the  lungs,  heart,  liver,  or  kidneys  is  so  often 
associated  with  chronic  arteritis  as  to  obscure  the  clinical  pict- 
ure. But  allowing  for  all  these  there  remains  a  large  class  of 
cases  in  which  chronic  arteritis  is  the  disease. 

I.  Chronic  Inflammation  of  the  Cerebral  Arteries. — The  cerebral 
symptoms  belonging  to  the  inflammation  of  these  arteries  have 
already  been  described. 


l6o  THE   ARTERIES. 

2.  Chronic  Inflammation  of  the  Medium-sized  and  S?naller  Arteries 
Throughout  the  Body. — At  first  for  a  number  of  years  the  patients 
only  suffer  from  impaired  nutrition,  a  disposition  to  become 
anaemic,  and  attacks  of  dyspnoea.  It  can  be  seen  and  felt  that  the 
walls  of  the  temporal  and  radial  arteries  are  thickened  and  that 
the  left  ventricle  of  the  heart  is  hypertrophied.  At  the  times 
when  the  patient  has  dyspnoea  the  tension  of  the  pulse  is  much 
increased. 

For  a  considerable  length  of  time  tlie  nutrition  and  the  anae- 
mia can  be  improved  by  climate  and  by  diet.  The  attacks  of 
dyspnoea  can  be  controlled  bv  the  drugs  which  dilate  the  arteries. 
But  sooner  or  later  the  patients  get  worse.  Some  of  them  get 
up  a  dvspnoea  that  cannot  be  controlled,  the  action  of  the  hyper- 
trophied heart  fails,  and  the  patients  after  suffering  for  weeks 
or  months  with  the  most  distressing  dyspnoea  die.  In  other 
cases  death  takes  place  witli  cerebral  symptoms — sudden  uncon- 
sciousness, aphasia,  or  hemiplegia.  Cases  of  this  character  are 
of  ordinary  occurrence.  Much  less  common  are  the  cases  in 
which  the  symptoms  run  a  short  and  rather  acute  course.  For 
example,  in  the  "Transactions  of  the  London  Patliological  Soci- 
ety for  1S92  "  we  find  the  following  history  : 

A  girl,  aged  eleven,  in  the  summer  of  1891  had  a  week's  ill- 
ness, probably  to  be  attributed  to  infarctions  of  the  lung.  In 
January,  1892,  similar  symptoms  came  on,  the  pain  being  first  in 
the  left  side,  later  in  the  right  ;  the  cough,  with  blood-stained 
sputum,  persisted  up  to  the  end  of  the  illness.  On  February  7th 
the  legs  became  oedematous,  and  a  few  days  later  the  face.  It 
was  supposed  that  she  was  suffering  from  acute  nephritis.  The 
urine  contained  a  little  albumin,  and  was  very  much  reduced  in 
quantity.  The  child  seemed  to  die  of  uraemic  poisoning.  At  the 
autopsy  all  the  arteries  of  both  the  aortic  and  pulmonary  systems 
were  found  to  be  diseased.  There  was  consolidation  with  infarc- 
tions of  portions  of  both  lungs.  Both  renal  arteries  were  oc- 
cluded by  thrombi.  There  were  small  clots  in  each  of  the  lateral 
lobes  of  the  cerebellum.  There  was  hypertrophy  and  dilatation 
of  the  left  ventricle  of  the  heart. 

3.  Chronic  inflammation  of  the  femoral  arteries  and  their 
branches  cause  gangrene  of  the  toes,  or  of  the  legs. 

4.  Chronic  inflammation  of  the  aorta  just  above  the  aortic 
valves  may  narrow  the  coronary  arteries  and  cause  attacks  of  an- 
gina pectoris. 


THE    AORTA.  l6l 

5.  If  tlie  whole  of  the  arcli  of  the  aorta,  with  more  or  less  of 
the  rest  of  the  aorta,  are  involved  the  patients  may  have  symp- 
toms wliich  resemble  those  of  organic  heart  disease. 

The  symptoms  come  on  in  attacks,  the  intervals  between  the 
attacks  are  shorter  as  the  disease  advances.  The  cases  vary  as 
to  the  character  of  the  attacks. 

In  some  patients  there  is  dyspnoea  on  exertion,  or  spasmodic 
dyspnoea.  The  spasmodic  dyspnoea  is  not  attended  with  any 
evidence  of  contraction  of  the  bronchi,  or  of  the  arteries. 

In  others  there  are  attacks  of  pain  like  those  of  true,  or  of 
false,  angina. 

In  others  there  are  repeated  attacks  of  epigastric  pain  and 
vomiting. 

Or  there  may  be  congestion  and  oedema  of  the  lungs,  or 
chronic  congestion  of  tiie  kidneys,  or  general  dropsy. 

The  nutrition  of  the  patients  gradually  suffers  and  they  lose 
flesh  and  strengtii.  The  ventricles  of  the  heart  are  often  dilated, 
or  hypertropliied,  or  both.  There  may  be  a  systolic  murmur, 
or  a  double  murmur,  and  dulness  on  percussion  over  the  arch  of 
the  aorta. 

The  natural  course  of  the  disease  is  to  grow  steadily  worse 
and  to  terminate  fatally,  but  yet  for  a  time  the  symptoms  are  not 
continuous,  but  come  on  in  attacks. 

6.  The  inflammation  of  the  aorta  may  be  accompanied  with 
the  formation  of  thrombi  on  its  roughened  inner  surface. 

Large  thrombi  in  the  arch  of  the  aorta  may  cause  urgent 
dyspnoea,  cyanosis,  vomiting,  prostration,  absence  of  the  heart- 
sounds  and  of  arterial  pulsation,  and  death  within  a  few  days. 

Large  thrombi  in  the  abdominal  aorta  produce  pain,  tender- 
ness, and  loss  of  power  in  the  legs,  pain  and  paralvsis  of  the  rec- 
tum, and  finally  gangrene  of  the  legs. 

Fragments  of  such  thrombi  may  be  detached  and  lodged  as 
emboli  in  the  arteries  of  the  brain  or  of  the  extremities. 

Aneurisms  of  the  Aorta. 

Fusiform  and  sacculated  aneurisms  occur  either  separately  or 
together.  The  fusiform  dilatations  may  involve  the  arch  alone 
or  the  whole  aorta.  The  sacculated  aneurisms  have  a  small  or  a 
large  opening.  The  sacs  themselves  are  small,  or  reach  a  large 
size,  they  are  either  single  or  multiple. 


1 62  THE   AORTA. 

Causes. — Aneurisms  of  the  aorta  are  especially  common  in 
males  between  the  ages  of  thirty  and  fifty  years,  in  persons  who 
have  constitutional  syphilis  ;  in  those  who  hav^e  chronic  inflam- 
mation of  the  aorta  ;  and  in  those  whose  occupation  involves 
severe  muscular  exertion. 

Situation. — Sibson  gives  the  seat  c^f  860  cases  of  aneurism  of 
the  aorta  as  follows  : 

Of  the  arch  of  the  aorta,  480. 

At  the  sinuses  of  Valsalva,  87, 

Of  the  ascending  portion  of  the  arch,  141. 

On  the  transverse  portion  of  the  arch,  120. 

Of  the  ascending  and  transverse  portions  of  the  arch  to- 
gether, 112. 

Of  the  descending  portion  of  the  arch,  72. 

Of  the  transverse  a-  d  descending  portions  of  the  arch  to- 
gether, 20. 

Of  the  whole  arch,  28. 

Of  the  thoracic  aorta,  71. 

Of  the  abdom.inal  aorta  at  tlie  coeliac  axis,  131. 

Of  the  lower  part  of  the  abdominal  aorta,  26. 

Symptoms. — These  are  due  to  the  presence  of  the  aneurismal 
tumor,  to  its  pressure  on  the  surrounding  parts,  and  to  its  effect 
on  the  circulation  of  the  blood.  The  presence  of  the  tumor  is 
more  or  less  easily  detected,  according  to  its  size  and  position. 

The  large  tumors  push  out  tiie  wall  of  the  chest  or  of  the  ab- 
domen, can  be  seen  and  felt  to  pulsate,  and  give  a  double  mur- 
mur and  a  thrill.  Smaller  tumors  within  the  thorax  only  give 
dulness  on  percussion,  with  sometimes  in  addition  a  double 
murmur.  Very  small  and  deeply  situated  aneurisms  give  no 
physical  signs. 

Fusiform  aneurisms  can  hardly  be  said  to  give  a  tumor  in  the 
thorax.  They  may  give  dulness  on  percusssion  and  a  svstolic 
murmur.  In  the  abdomen  the  dilated  artery  can  be  felt,  its  ex- 
aggerated pulsation  recognized,  and  a  systolic  murmur  heard 
over  it. 

The  aneurisms  are  for  the  most  part  so  situated  that  they 
press  upon  the  adjacent  tissues  and  so  produce  a  variety  of 
symptoms.  Pressure  on  the  descending  vena  cava  causes  venous 
congestion  of  the  head  and  neck.  Pressure  on  the  pulmonary 
artery,  on  the  right  auricle,  and  on  the  upper  part  of  the  ventri- 
cles, interferes  with   the  action  of   the  heart  and   causes  conges- 


THE   AORTA.  163 

tion  of  the  lungs.  Pressure  on  the  large  bronchi  and  on  the 
trachea  sets  up  inflammation  (;f  their  walls  and  mucous  mem- 
branes. This  inflammation  often  extends  up  the  trncliea  to  the 
larynx  and  produces  cough  and  dyspnoea,  or  down  the  bronchi 
into  tlie  lungs  and  sets  up  a  broncho-pneumonia.  The  pressure 
also  directly  produces  dyspnoea  and  tubular  breathing  which  can 
be  heard  over  the  lungs.  Pressure  on  the  oesophagus  causes 
difficulty  in  swallowing.  Pressure  on  the  recurrent  laryngeal 
nerve  produces  paralysis  of  one  of  the  vocal  cords.  Pressure  on 
the  brachial  plexus  of  nerves  produces  pain.  Pressure  on  the 
vertebral  column  regularly  causes  erosion  of  the  bones  with  very 
great  pain. 

The  aneurisms  and  the  accompanying  inflammation  of  the 
aorta  may  cause  venous  congestion  throughout  the  body,  and 
dilatation  and  hypertrophy  of  the  left  ventricle  of  the  heart. 

All  sacculated  aneurisms  are  liable  to  rupture. 

ANEURISMS    AT    THE    SINUSES    OF    VALSALVA. 

These  aneurisms  are  sacculated,  and  are  most  frequently 
given  off  from  the  right  coronary  sinus.  Small  aneurisms  in  this 
situation  give  no  symptoms  until  the  time  comes  when  they  rupt- 
ure within  the  pericardium  and  cause  sudden  death.  Larger 
aneurisms  may  compress  and  erode  the  pulmonary  artery,  the 
right  auricle,  the  right  ventricle,  or  the  descending  vena  cava. 

Corresponding  to  the  seat  of  the  aneurism  there  is  an  area  of 
ckdness  or  a  pulsating  tumor,  either  to  the  right  or  left  of  the 
sternum,  at  about  the  third  interspace. 

There  is  a  murmur  in  thirty-four  percent,  of  the  cases. 

Dyspnoea  in  thirty-eight  per  cent. 

Cough  in  twenty-four  per  cent. 

Pain  in  twenty-one  per  cent. 

Enlarged  heart  in  twenty-nine  per  cent. 

Rupture  of  the  aneurism  within  the  pericardium  in  fort)^- 
eight  per  cent. 

Into  the  pulmonary  artery  in  13^%  per  cent. 

Into  the  right  auricle  in  8^^f  per  cent. 

Into  the  right  ventricle  in  five  per  cent. 

Into  the  left  ventricle  in  five  per  cent. 


l64  THE   AORTA. 


ANEURISMS     OF      THE     ASCENDING     PORTION     OF    THE      ARCH      OF      THE 

AORTA, 

These  aneurisms  are  sacculated  in  fifty-one  per  cent.,  fusiform 
in  thirty-seven  per  cent.,  of  tlie  cases.  The  ascending  portion  of 
the  arch  of  the  aorta  rests  upon  the  pulmonary  artery  and  the 
left  side  of  the  trachea.  On  its  right  side  is  the  superior  vena 
cava  ;  on  its  left  side  the  pulmonary  artery.  Most  of  the  saccu- 
lated aneurisms  are  given  off  from  the  anterior  and  right  aspects 
of  the  wall  of  the  aorta,  and  a  comparatively  small  number  from 
the  posterior  and  left  aspects. 

They  give  an  area  of  dulness,  or  a  pulsating  tumor  to  the 
right  of  tlie  sternum,  at  the  second  interspace  ;  much  less  fre- 
quently on  the  left  side  of  the  sternum.  They  may  compress 
the  right  lung,  the  vena  cava,  the  left  lung,  the  trachea,  the 
oesophagus,  the  pulmonary  artery,  tlie  right  bronchus,  or  the 
left  bronchus. 

A  murmur  is  present  in  twenty-three  per  cent,  of  the  cases, 
dyspnoea  in  fifty-one  per  cent.,  cough  in  thirty-six  per  cent., 
stridor  in  four  per  cent.,  pain  in  the  chest  in  twenty-nine  per 
cent.,  pain  in  the  neck  and  shoulders  in  ten  per  cent.,  pain  in  the 
right  arm  in  two  per  cent. 

The  patients  remain  in  good  health  and  without  symptoms 
up  to  the  time  of  their  death  in  eleven  per  cent,  of  the  cases. 

Rupture  of  the  aneurism  occurs  in  fifty-seven  per  cent,  of  the 
cases.  The  rupture  is  through  the  wall  of  the  thorax  in  eight 
per  cent,  of  the  cases,  into  the  pericardial  sac  in  twenty-two  per 
cent.,  into  the  pulmonary  artery  in  four  per  cent.,  into  the  right 
auricle  in  one  per  cent.,  into  the  descending  vena  cava  in  five 
per  cent.,  into  the  trachea  in  one  per  cent,  into  the  right  bronchus 
in  three  per  cent.,  into  the  right  lung  in  five  per  cent.,  into  the 
left  lung  in  two  per  cent.,  into  the  right  pleura  in  two  per  cent., 
into  the  left  pleura  in  four  per  cent. 

ANEURISMS  OF  THE  TRANSVERSE   PORTION  OF  THE  ARCH  OF  THE 

AORTA. 

The  transverse   portion  of  the   arch  passes  backward  and  to 
the  left,  over  the  left  bronchus.  The  left  recurrent  laryngeal  nerve 
passes  behind  and  against  this  portion  of  the  arch.     The  carotid 
subclavian,  and  innominate  arteries  are  given  off  from  it. 


THE   AORTA.  165 

These  aneurisms  are  most  frequently  sacculated.  The  larger 
number  are  given  off  from  the  posterior  wall  of  the  aorta.  A 
smaller  number  from  tlie  anterior  or  upper  wall. 

Those  given  off  from  the  posterior  wall  soon  compress  the 
trachea,  or  bronchi,  or  oesophagus,, and  the  recurrent  laryngeal 
nerve.  The  patients  very  early  have  dyspnoea,  cough,  stridor, 
paralysis  of  one  of  the  vocal  cords,  tubular  breathing  over  one  or 
both  lungs,  but  the  physical  signs  of  the  tumor  are  absent  or  ob- 
scure until  it  reaches  a  large  size.  These  aneurisms  are  apt  to 
rupture  into  a  bronchus,  into  the  trachea,  or  into  the  oesophagus. 

The  aneurisms  given  oft"  from  the  anterior  and  upper  wall 
soon  give  the  pliysical  signs  of  a  tumor.  They  partly  occlude  the 
large  arteries  given  off  from  this  part  of  the  aorta,  and  diminish 
the  pulsation  of  the  carotid  and  radial  arteries.  They  must,  how- 
ever, attain  a  considerable  size  before  they  can  exert  much  press- 
ure on  surrounding  parts. 

A  pulsating  tumor  at  or  above  the  level  of  the  manubrium  is 
found  beneath  the  sternum  in  nineteen  per  cent,  of  the  cases  ;  to 
the  right  of  the  sternum  in  i2-j5jj  per  cent.;  to  the  left  of  the 
sternum  in  i2y^q  per  cent. 

A  murmur  is  present  in  fifteen  per  cent,  of  the  cases,  dyspnoea 
in  seventy-one  per  cent.,  cough  in  fifty-seven  per  cent.,  haemopty- 
sis in  nineteen  per  cent.,  stridor  in  47^®g-  per  cent.,  dysphagia 
in  thirty-one  per  cent..,  pain  in,  thirty-six  per  cent.,  weakening  of 
one  radial  pulse  in  twentv-six  per  cent. 

The  aneurisms  rupture  externally  in  six  per  cent,  of  the  cases  ; 
into  the  pericardium  in  two  per  cent,,  into  the  right  pleura  in 
two  per  cent.,  into  the  left  bronchus  in  four  per  cent.,  into  the 
left  pleura  in  five  per  cent.,  into  the  oesophagus  in  six  per  cent., 
into  the  pulmonary  artery  in  one  per  cent.,  into  the  descending 
vena  cava  in  one  per  cent.,  into  the  trachea  in  ten  per  cent. 


ANEURISMS    OF     BOTH    THE     ASCENDING     AND     TRANSVERSE     PORTIONS 
OF    THE    ARCH    OF    THE    AORTA. 

These  aneurisms  are  fusiform  in  eighty-five  per  cent,  of  the 
cases.  Most  of  them  soon  reach  a  considerable  size.  There  is 
dulness  on  percussion,  or  a  pulsating  tumor,  most  frequently  on 
the  right  side  of  the  sternum,  often  beneath  the  sternum,  less 
often  on  the  left  side  of  the  sternum. 


1 66  THE   AORTA. 

The  pressure  of  the  tumor  presses  forward  and  erodes  the 
sternum  and  the  ribs.  The  trachea  is  compressed  in  thirty-three 
per  cent,  of  the  cases,  the  superior  vena  cava  in  ten  per  cent., 
the  oesophagus  in  nine  per  cent. 

Dyspnoea  is  present  in  seventy-four  per  cent,  of  the  cases, 
cough  in  forty-seven  per  cent.,  haemoptysis  in  ten  per  cent., 
stridor  in  seventeen  per  cent.,  dysphagia  in  twenty-one  per  cent, 
pain  in  the  chest  in  thirty  per  cent.,  pain  in  the  back  in  ten 
per  cent.,  pain  in  the  arms  in  eighteen  per  cent.,  pain  in  the  neck 
in  four  per  cent. 

The  right  pulse  is  feeble  in  six  per  cent,  of  the  cases,  the  left 
pulse  in  three  per  cent. 

The  aneurisms  rupture  into  the  pericardium  in  ten  per  cent, 
of  the  cases,  into  the  pulmonary  artery  in  ly^^  per  cent.,  into  the 
vena  cava  in  four  per  cent.,  into  the  trachea  in  four  per  cent., 
into  the  right  pleura  in  three  per  cent.,  into  the  left  pleura  in  one 
per  cent. 


ANEURISMS    OF    THE    DESCENDING    PORTION    OF     THE    ARCH    OF     THE 

AORTA. 

The  descending  portion  of  the  arch  lies  at  first  on  the  left 
lung  and  the  oesophagus,  and  at  last  rests  on  the  left  half  of  the 
body  of  the  fifth  or  sixth  dorsal  vertebra,  where  the  oesophagus 
is  on  the  right  side  of  the  aorta.  In  front  of  it  are  the  left  bron- 
chus and  the  pulmonary  artery. 

The  aneurisms  are  sacculated  in  eighty-one  per  cent,  of  the 
cases,  fusiform  in  eight  per  cent. 

The  aneurisms  are  given  off  from  the  posterior  and  left  walls 
of  the  aorta. 

The  vertebrae  are  eroded  in  forty-two  per  cent,  of  the  cases, 
the  left  ribs  in  front  in  four  per  cent.,  the  trachea  is  compressed 
in  i2^j^  per  cent,  of  the  cases,  the  left  bronchus  in  2,1  jn  per  cent., 
the  oesophagus  in  thirty-one  per  cent.,  the  left  lung  in  forty-eight 
per  cent.,  the  right  lung  in  six  per  cent. 

The  presence  of  the  aneurismal  tumor  cannot  usually  be 
made  out  by  physical  signs  until  it  has  reached  a  considerable 
size. 

A  murmur  is  present  in  twenty-three  per  cent,  of  the  cases, 
dyspnoea  in  fifty  per  cent.,  cough  in  forty-six  per  cent.,  stridor  in 


THE   AORTA.  167 

twenty-five  per  cent.,  dysphagia  in  tliiity-three  per  cent.,  pain  in 
tlie  cliest  in  fifty-two  per  cent. 

The  aneurisms  rupture  into  the  left  pleura  in  twenty-tliree 
per  cent,  of  the  cases,  into  the  right  lung  in  six  per  cent.,  into 
the  right  pleura  in  twelve  per  cent.,  into  the  trachea  in  four  per 
cent.,  into  the  left  lung  in  four  per  cent. 


ANEURISMS  OF  THE  THORACIC  AORTA. 

These  are  sacculated  in  thirty-five  per  cent,  of  the  cases,  fusi- 
form in  twenty-eight  per  cent. 

Erosion  of  the  vertebi'ze  occurs  in  seventy-four  per  cent,  of 
the  cases.  The  oesophagus,  the  left  lung,  or  the  right  lung  may 
be  compressed,  the  heart  may  be  displaced  forward,  there  may 
be  a  pulsating  tumor  in  the  dorsal  or  axillary  regions. 

A  murmur  is  present  in  four  per  cent,  of  the  cases,  dyspnoea 
in  twenty-six  per  cent.,  cough  in  twenty-four  per  cent.,  dysphagia 
in  nine  per  cent.,  pain  in  the  back  in  forty-three  per  cent.,  in  the 
chest  in  twenty-nine  per  cent.,  in  the  abdomen  in  thirteen  pei 
cent.,  in  the  left  lumbar  region  in  nineteen  per  cent. 

The  aneurisms  rupture  into  the  trachea  in  two  per  cent,  of 
the  cases,  into  the  left  lung  in  thirteen  per  cent.,  into  the  left 
pleura  in  twenty-six  per  cent.,  into  the  right  lung  in  six  per 
cent.,  into  the  right  pleui"a  in  thirteen  per  cent. 


ANEURISMS    OF    THE    ABDOMINAL    AORTA, 

These  are  usually  sacculated.  The  larger  number  are  situ- 
ated near  the  coeliac  axis.  They  are  given  off  with  about  equal 
frequency  from  the  anterior  and  posterior  walls  of  the  aorta. 

Tliose  on  the  posterior  walls  very  early  erode  the  vertebras. 
They  give  pain  referred  to  the  vertebrae  and  radiating  down. 
While  the  tumors  remain  of  small  size  it  is  often  difficult  to  make 
them  out. 

The  anterior  aneurisms  give  pain  referred  to  the  epigastrium 
and  the  anterior  portion  of  the  abdomen.  The  tumors  are  easily 
made  out  by  palpation. 

These  aneurisms  rupture  into  the  peritoneal  cavity,  behind 
the  peritoneum,  into  the  mesentery,  and  into  the  right  or  left 
pleural  cavity.     The  blood   may  escape  at   once  into  the  perito- 


l68  THE   AORTA. 

neal  cavity  and  cause  death,  or  it  may  be  for  a  time  eld  in  be- 
hind the  peritoneum  and  a  false  aneurism  be  thus  formed. 

There  may  be  incomplete  or  complete  obstruction  of  the 
aorta  by  thrombi  extending  from  the  aneurismal  sac. 

Treatment, — The  medical  treatment  of  aneurism  of  the  aorta 
consists  in  determining  for  each  patient,  experimentally,  whether 
he  is  better  for  rest  or  for  regulated  exercise,  and  in  the  adminis- 
tration of  the  iodide  of  potash.  The  iodide  is  given  in  doses  of 
from  five  to  twenty  grains,  three  or  four  times  a  day.  In  favor- 
able cases  the  aneurism  is  diminished  in  size,  the  symptoms  are 
alleviated,  and  life  is  prolonged. 


THE    CESOPHAGUS. 


Stenosis. 

1.  Congenital  stenosis  of  the  oesopliagns  is  rare.  It  is  most 
frequently  seen  in  children,  who  die  early.  Exceptionally,  the 
patients  survive  to  adult  life,  but  with  constantly  increasing  dif- 
ficulty in  swallowing. 

2.  Stenosis  by  compression  is  due  to  the  pressure  of  aneur- 
isms, of  tumors  of  the  thyroid,  and  of  tumors  of  the  neck  and 
the  thorax.  The  difficulty  in  swallowing  is  only  one  of  the 
symptoms  of  the  tumor. 

3.  Stenosis  from  tumors  of  the  posterior  wall  of  the  pharynx, 
either  polypoid  or  diffuse. 

4.  Cicatricial  stenosis  from  the  contraction  following  the  le- 
sions inflicted  by  irritant  poisons.  These  require  surgical  treat- 
ment. 

5.  Stenosis  due  to  syphilitic  inflammation  of  the  wall  of  the 
oesophagus. 

6.  Carcinoma  of  the  oesophagus. 

The  new-growth,  of  flat-celled  epithelial  type,  begins  at  some 
part  of  the  wall  of  the  oesophagus,  and  soon  surrounds  it.  There 
are  masses  of  nevv-grow^th,  and  deep  ulcers  ;  either  may  be  the 
predominant  feature.  The  new-growth  involves  only  one  or  two 
inches  of  the  oesophagus,  or  a  much  larger  portion.  The  lower 
half  of  the  oesophagus  is  the  portion  most  frequently  involved. 
The  growth  may  remain  confined  to  the  wall  of  the  oesophagus, 
or  may  extend  to  the  trachea,  bronchi,  lungs,  pleura,  pericar- 
dium, and  vertebrae.  Metastatic  tumors  may  be  formed  in  tlie 
lymphatic  glands,  lungs,  and  liver.  A  cancer  of  the  stomach 
may  be  developed  at  the  same  time  with  a  cancer  of  the  oesopha- 
gus. 

The  disease  occurs  most  frequently  in  males  over  forty  years 
of  asre. 


I/O  THE   OESOPHAGUS. 

The  first  symptom  is  difficulty  in  swallowing.  This  begins 
with  difficulty  in  swallowing  large  pieces  of  solid  food,  then 
smaller  pieces  cannot  be  swallowed,  and,  finally,  not  even  liq- 
uids. The  progress  of  the  dysphagia  is  gradual,  and  often  inter- 
mittent. 

The  next  symptom  is  pain,  referred  to  the  upper  end  of  the 
sternum. 

It  is  not  until  the  tumor  has  existed  for  some  time,  and  the 
difficulty  in  swallowing  is  considerable,  that  there  is  much 
change  in  the  nutrition  of  the  patients.  But  after  they  have 
once  begun  to  emaciate  they  get  worse  very  rapidly. 

Life  may  be  prolonged  for  a  few  weeks  by  passing  tubes 
through  the  oesophagus  into  the  stomach,  and  by  the  use  of  rec- 
tal alimentation. 

7.  Spasmodic  stricture  occurs  in  young  and  old  persons,  in 
both  males  and  females.  There  is  sometimes  a  history  of  hys- 
teria, sometimes  one  of  sudden  choking. 

The  one  symptom  is  difficulty  in  swallowing,  sometimes  at- 
tended with  pain. 

The  dysphagia  may  be  complete,  or  partial.  It  occurs  in  at- 
tacks which  last  for  minutes,  days,  weeks,  or  months,  and  which 
are  repeated  at  short  or  long  intervals.  It  differs  from  the  dys- 
phagia of  organic  disease  in  that  it  does  not  gradually  get  worse, 
but  is  as  bad  at  first  as  later,  and  there  is  as  much  difficulty  in 
swallowing  fluids  as  solids.  The  contraction  of  the  oesophagus 
is  just  above  the  stomach.  I  have  seen  one  case,  of  ten  years' 
duration,  in  which  there  was  a  dilatation  of  the  oesophagus 
above  the  stricture,  in  which  the  food  collected. 

The  treatment  of  spasmodic  stricture  is  fairly  satisfactory, 
but  it  has  to  be  continued  for  a  long  time.  It  consists  in  pass- 
ing a  tube  of  moderate  size  into  the  stomach  one  or  more  times 
every  day,  washing  out  the  stomach,  and  then  introducing  fluid 
food  through  the  tube. 

Dilatation. 

I.  Fusiform  dilatations  'of  the  oesophagus  are  secondary  to 
stenosis,  or  occur  without  discoverable  cause.  They  involve  a 
part,  or  the  entire  length,  of  the  oesophagus.  The  wall  of  the 
dilated  oesophagus  is  often  thickened. 

The  symptoms  are  difficulty  in  swallowing,  vomiting,  regur- 
gitation of  food,  and  rumination. 


THE    (]':SOPIIAGUS.  I/I 

Tlie  treatment  consists  in  the  dilatation  of  the  stenosis  and 
the  feeding  the  patients  with  tlie  stomach-tube, 

2.  Sacculated  dilatations  are  of  two  kinds. 

(a)  Small  sacs  are  formed  in  the  lower  part  of  the  posterior 
wall  of  the  pharynx,  which  afterward  become  larger. 

They  are  more  common  in  males  than  in  females,  and  belong- 
to  adult  life. 

How  it  is  that  these  sacs  begin  to  be  formed  is  not  well  un- 
derstood. But  as  soon  as  they  have  reached  such  a  size  that  the 
food  can  enter  and  remain  in  them,  they  rapidly  enlarge  behind 
the  oesophagus  and  compress  it. 

There  is  difficulty  in  swallowing,  at  first  slight,  but  increasing 
with  the  pressure  of  the  sac  on  the  oesophagus. 

There  is  regurgitation  of  the  food  from  the  sac,  rumination, 
and  vomiting.  There  may  be  a  tumor  in  the  neck  which  can  be 
emptied  by  pressure. 

The  only  treatment  which  has  thus  far  been  employed  is  to 
feed  the  patients  with  the  stomach-tube, 

(i)  Small  sacs  are  given  off  from  the  anterior  wall  of  the 
oesophagus,  at  about  its  middle.  They  seem  to  be  due  to  an  in- 
flammation of  the  bronchial  glands,  an  extension  of  this  inflam- 
mation to  the  wall  of  the  oesophagus,  and  traction. 

These  sacs  give  no  oesophageal  symptoms,  but  thev  may  per- 
forate and  so  give  rise  to  inflammatory  processes  in  the  medias« 
tinum. 


THE   STOMACH. 


The  oesophageal  end  of  the  stomach  is  on  a  level  with  the 
eighth  dorsal  vertebra  behind  and  the  sixth  left  interspace  close 
to  the  sternum  in  front.  The  pyloric  end  of  the  stomach  is  at 
the  level  of  the  eighth  costal  cartilage,  just  to  the  right  of  the 
sternum,  and  is  covered  by  the  liver.  The  oesophageal  end  of 
the  stomach  is  fixed,  but  its  pyloric  end  is  movable  and  often  dis- 
placed. The  greater  curvature  of  the  stomach  is  close  to  the 
colon,  and  its  fundus  touches  the  spleen. 

The  outer  surface  of  the  stomach  is  covered  with  a  connec- 
tive-tissue membrane — the  peritoneal  coat  ;  beneath  this  is  the 
muscular  coat ;  tlien  comes  the  connective-tissue  coat  ;  then  a 
thin  layer  of  muscular  fibres,  the  muscularis  mucosae  ;  and  lastly, 
the  glandular  coat.  The  glandular  coat  of  the  stomach  is  com- 
posed of  the  peptic  tubules  which  form  the  gastric  juice,  and  the 
mucous  tubules  which  form  mucus.  The  mucous  tubules  are 
not  nearly  as  numerous  as  the  peptic  tubules,  and  are  situated 
at  the  pyloric  end  of  the  stomach.  All  the  tubules  are  held  to- 
gether by  a  stroma  of  connective  tissue.  About  the  blind  ends 
of  the  tubules  are  small  lymph-nodes.  The  entire  wall  of  the 
stomach  is  well  supplied  with  blood-vessels,  lymphatics,  and 
nerves. 

It  is  the  function  of  the  stomach  to  receive  the  food,  to  digest 
certain  portions  of  it,  and,  after  a  proper  lapse  of  time,  to  expel 
it  all,  digested  and  undigested,  into  the  small  intestines. 

The  nitrogenized  substances — albumin,  gluten,  fibrine,  ca- 
seine,  and  gelatine — are  acted  upon  by  the  gastric  juice  and  con- 
verted into  peptones.  The  starches  are  partly  changed  into 
sugar,  and  the  fats  are  softened. 

The  more  thoroughly  the  process  of  the  stomach  digestion  is 
studied,  the  more  evident  it  becomes  that  it  is  a  complex  one 
carried    out  by  a  variety  of  ferments.     The   knowledge    of  the 


THE   STOMACH.  1/3 

subject  obtained  by  the  physiolog'ical  chemists  has  not  yet  been 
put  in  a  shape  available  to  the  physician. 

In  a  healthy  person,  while  the  food  is  being  received  into  the 
stomach  and  while  gastric  digestion  is  going  on,  the  pylorus  is 
closed,  but  the  muscular  coat  of  the  stomach  is  in  activity,  mov- 
ing about  the  contained  food.  After  about  four  hours  the  neces- 
sary changes  in  tiie  stomach  should  be  completed,  tiie  contents 
of  the  stomach  expelled  through  the  pylorus,  and  the  organ  then 
remains  empty  and  contracted  until  the  next  ingestion  of  food. 

Methods  of  Examination. — The  portions  of  the  stomach  which 
are  not  covered  by  the  wall  of  the  chest  or  the  liver,  are  available 
for  palpation  and  percussion.  These  portions  of  the  stomach 
are  made  more  evident  by  causing  the  patient  to  take  a  deep 
breath  and  depress  the  diaphragm. 

Tumors  and  thickenings  of  the  wall  of  the  stomach  can 
usually  be  felt  without  difficulty. 

If  the  stomach  is  dilated,  its  outlines  can  sometimes  be  seen 
through  the  anterior  abdominal  wall,  especially  when  the  patient 
takes  deep  inspirations.  It  is  not  easy  to  feel  the  wall  of  the 
stomach  unless  it  is  thickened,  but  in  some  cases  the  greater  cur- 
vature can  be  made  out  by  percussion.  It  has  been  recommended 
to  distend  the  stomach  with  carbonic  dioxide  by  giving  the  pa- 
tient first  some  bicarbonate  of  sodium  and  then  tartaric  acid,  or 
by  pumping  air  into  it,  or  by  filling  it  with  water  in  order  to 
determine  whether  the  organ  is  dilated.  As  a  rule,  these  pro- 
cedures are  to  be  avoided  as  unnecessary  and  not  devoid  of 
danger. 

Dilatation  of  the  stomach  is  most  easily  made  out  by  means 
of  the  stomach-tube.  The  length  of  tube  which  has  to  be  in- 
serted before  the  water  will  run  in  and  out  from  the  stomach,  and 
the  quantity  and  character  of  the  contents  of  the  stomach  give 
the  necessary  information. 

In  most  stomachs  within  an  hour  after  eating  a  splashing 
sound  can  be  produced  by  palpation.  This  sound  is  more  evi- 
dent if  the  stomach  is  dilated.  It  is  not,  however,  by  itself  an 
evidence  of  dilatation  of  the  stomach.  Similar  splashing  sounds 
can  be  produced  in  the  colon. 

The  contents  of  the  stomach  can  be  removed  through  the 
stomach -tube,  by  expression  or  aspiration,  and  subjected  to 
chemical  analysis.  It  is  customary  to  test  for  the  presence  and 
quantity  of  HCl,  of  lactic  acid,  and  of  the  fatty  acids.     Of  much 


174  THE   STOMACH. 

more  practical  consequence  is  the  determination  witli  tlie  tube  of 
the  capacity  of  the  stomacli  for  digesting  different  kinds  of  food. 
In  the  management  of  diseases  of  the  stomach  the  tube  is 
necessarily  in  daily  use.  It  is  important,  tlierefore,  that  the  tube 
should  be  of  such  a  size  and  consistence  as  to  be  comfortable  to 
the  throat,  and  that  the  physician  should  acquire  the  dexterity 
necessary  to  pass  it  quickly  and  easily. 

Disturbances   of    the    Functions   of    the    Stomach    without 
Organic  Disease.     Gastric  Dyspepsia. 

Disturbances  of  the  functions  of  the  stomach  without  struct- 
ural disease  of  its  walls  are  produced  in  a  variety  of  ways. 

I.  The  habitual  ingestion  of  food  in  excessive  quantities,  or 
of  improper  quality,  may  after  a  time  cause  gastric  symptoms. 
It  must,  however,  be  remembered  that  gastric  symptoms  are  often 
due  to  entirely  different  causes,  and  that  too  little  food  is  as  bad 
as  too  much. 

One  of  the  simplest  disturbances  due  to  an  excessive  ingestion 
of  food  is  seen  in  children.  A  child  at  some  particular  meal 
overfills  its  stomach.  The  pylorus  remains  closed  and  no  gastric 
digestion  takes  place.  After  some  hours  the  child  has  abdominal 
pain,  ra;:>id  heart  action,  a  cold  skin,  and  sometimes  marked 
prostration.  Finally  it  vomits  the  food  in  nearly  the  same  con- 
dition as  when  it  was  taken  into  the  stomach,  and  is  at  once  re- 
lieved of  all  symptoms. 

The  same  thing  can  be  seen  in  adults.  A  large  meal  is  eaten, 
little  or  no  gastric  digestion  takes  place,  the  pylorus  remains 
closed,  the  stomach  is  distended  with  undigested  food.  After  a 
number  of  hours  the  patient  has  the  feeling  of  vertigo  or  of  faint- 
ness,  or  he  may  fall  to  the  ground  unconscious.  Then  there  is  a 
profuse  vomiting  of  the  contents  of  the  stomach. 

In  adults  habitual  over-eating  may  cause  chronic  gastritis  and 
dilatation  of  the  stomach,  but  it  is  much  more  apt  to  cause  symp- 
toms referable  to  disturbances  of  the  functions  of  the  liver  — feel- 
ings of  lassitude  and  depression,  headache,  constipation,  diarrhoea, 
flatulence,  an  excess  of  urates  in  the  urine. 

The  habitual  eating  of  improper  food  results  in  an  impair- 
ment of  nutrition,  for  not  only  is  the  improper  food  bad  in  itself, 
but  it  takes  the  place  of  wholesome  food. 

The  treatment  of  these  cases  consists  in  a  regulation  of  the 


THE   STOMACH.  1/5 

diet.  In  the  bad  cases  the  patients  must  be  put  for  a  time  on 
the  exclusive  use  of  milic,  or  of  scraped  beef,  but  neither  of  tiiese 
exclusive  diets  can  be  continued  uitli  advantage  for  any  great 
length  of  time.  The  use  of  all  sorts  of  heakli-foods,  peptonized 
foods,  pepsin  and  pancreatine,  is  to  be  avoided.  The  patients 
must  be  educated  to  eat  meat,  starches,  fats,  vegetables,  and 
fruits  in  proper  quantities.  In  doing  this  the  use  of  the  stomach- 
tube,  about  four  hours  after  one  of  the  meals,  is  of  much  service 
as  a  guide  to  the  particular  articles  of  food  which  are  best  di- 
gested and  remain  the  shortest  time  in  the  stomach. 

2.  Changes  in  the  gastric  juice.  The  two  most  marked  changes 
in  the  gastric  juices  are  :  such  a  change  in  its  composition  as 
renders  it  unable  to  perform  stomach  digestion,  or  increased 
quantity  and  hyperacidity. 

(a)  Changes  in  the  composition  of  the  gastric  juice  of  such  a 
character  that  stomach  digestion  is  imperfectly  performed. 

This  condition  is  seen  in  persons  who  have  had  chronic  gas- 
tritis for  a  long  time,  with  changes  in  the  glandular  coat  of  the 
stomach.  It  is  also  seen  in  young  persons  in  whom  there  is  no 
evidence  of  disease  of  the  glandular  coat. 

The  patients  have  no  appetite,  or  even  a  distaste  for  food.  In 
some  there  is  occasional  nausea,  vomiting,  and  pain  after  eating. 
Tlie  bowels  are  usually  constipated.  The  nutrition  suffers 
not:iceably,  the  patients  lose  flesh  and  strength.  Besides  the 
gastric  symptoms  there  are  often  a  variety  of  accessory  symp- 
toms of  nervous  and  hysterical  character.  It  is  not  uncommon 
to  find  persons  belonging  to  this  class  who  do  not  complain  of 
any  gastric  symptoms,  but  only  of  the  loss  of  nutrition  and  some 
disturbance  of  sensation. 

On  the  other  hand  we  must  not  confound  with  this  class  the 
persons  who  complain  of  gastric  pain  and  oppression,  loss  of  ap- 
petite and  nausea,  but  in  whom  gastric  digestion  is  well  per- 
formed. 

The  diagnosis  is  made  with  the  help  of  the  stomach-tube. 

There  will  be  found  a  considerable  number  of  persons  in 
whom  more  or  less  partly  digested  food  is  always  present  in  the 
stomach.  The  problem  in  these  persons  is  to  improve  gastric  di- 
gestion. It  would  seem  as  if  this  could  be  done  by  the  use  of 
pepsin,  or  hydrochloric  acid,  or  partly  digested  foods,  but  it  will 
be  found  that  no  permanent  improvement  can  be  effected  in  this 
way.     There   is  no   one   rule  for  the   management   of   all  these 


17^  THE   STOMACH. 

patients,  but  the  general  plan  is  to  improve  the  general  health  by 
massage,  baths,  exercise,  and  travel,  and  to  feed  the  patients  as 
well  as  can  be  done.  The  method  of  feeding  has  to  be  found  out 
for  each  person  with  the  stomach-tube.  We  try  the  simple 
articles  of  food  —  milk,  eggs,  kumyss,  meat,  beef-juice,  gruels, 
etc. — and  see  which  ones  leave  the  cleanest  stomach  in  the  short- 
est time.  In  this  way  we  get  a  guide  as  to  the  best  kind  of  food 
and  the  proper  intervals  between  taking  food.  As  the  patients 
improve  we  gradually  add  other  kinds  of  food.  It  requires  a 
number  of  months  to  get  these  persons  back  to  a  natural  condi- 
tion of  health. 

{l>)  The  gastric  juice  may  contain  an  excessive  quantity  of 
hydrochloric  acid,  and  be  itself  produced  in  too  large  quantities. 
The  most  marked  symptoms  of  this  condition  are  epigastric  pains 
and  vomiting.  To  determine  this  condition  accurately  the 
stomach  should  be  washed  out  in  the  evening  and  its  contents 
aspirated  the  next  morning  before  the  ingestion  of  food  or  fluid. 

The  milder  cases  are  benefited  by  the  use  of  alkalies,  but  the 
only  satisfactory  treatment  is  the  systematic  washing  out  of  the 
stomach. 

Temporary  insufficiency  of  the  gastric  juice  may  be  caused  by 
a  variety  of  nervous  and  mental  conditions. 

3.  The  muscular  coat  of  the  stomach  may  cease  to  perform 
properly  its  function  of  moving  and  expelling  the  food.  This 
condition  is  apt  to  be  slowly  developed,  so  that  it  is  not  until 
after  several  years  that  it  becomes  a  serious  evil.  The  insuffi- 
cient action  of  the  muscular  coat  of  the  stomach  allows  food  to 
remain  in  the  stomach  from  one  meal  to  another,  so  that  the 
organ  is  never  empty.  This  constant  presence  of  food  may  event- 
ually cause  chronic  gastritis  or  dilatation  of  the  stomach.  The 
symptoms  at  first  come  on  in  attacks  which  last  for  several  days  ; 
between  the  attacks  the  patient  is  well.  As  time  goes  on  the 
attacks  become  more  frequent  and  of  longer  duration,  and  finally 
the  symptoms  are  continuous.  The  principal  symptom  is  pain  of 
greater  or  less  severity  referred  to  the  region  of  the  stomach. 
To  the  pain  are  regularly  added  after  a  time  constipation,  nausea, 
vomiting,  and  finally  loss  of  flesh  and  strength. 

During  the  earlier  periods  of  their  trouble  the  patients  im- 
prove under  an  absolute  diet  of  milk  or  of  meat,  but  the  only 
really  satisfactory  treatment  is  the  washing  out  of  the  stomach, 
with  a  regulated  diet. 


THE    STOMACH.  1 77 

4.  Disorders  of  the  colon — constipation,  chronic  inflamma- 
tion, or  carcinoma — may  be  accompanied  by  gastric  symptoms — 
pain,  nausea,  and  vomiting.  In  elderly  persons,  whenever  nau- 
sea and  vomiting  are  present  it  is  always  necessary  to  think  of  an 
accumulation  of  faeces  in  the  colon  as  the  probable  cause. 

5.  Diseases  of  the  uterus,  ovaries,  and  tubes  are  rather  fre- 
quently accompanied  by  loss  of  appetite,  nausea,  and  vomiting. 
These  symptoms  are  continuous,  or  come  on  in  attacks.  There 
may  really  be  chronic  gastritis,  or  inefficient  gastric  juice,  or 
retention  of  food  in  the  stomach  in  addition.  But  it  will  be 
found  that  the  treatment  of  the  stomach  is  unsatisfactory  unless 
the  disease  of  the  laterus,  ovaries,  or  tubes,  can  first  be  cured. 

6.  In  the  simple  anaemia  of  young  women  gastric  symptoms 
are  usually  present,  and  in  some  of  the  patients  are  especially 
severe.  Loss  of  appetite,  nausea,  and  vomiting  are  often  present, 
haematemesis  is  not  rare.  The  gastric  symptoms  may  be  so  marked 
as  to  make  it  easy  to  overlook  the  anaemia,  but  this  error  is 
readily  avoided  by  the  examination  of  the  blood. 

In  these  anaemic  patients  the  gastric  symptoms  promptly  dis- 
appear with  the  cure  of  the  anaemia. 

7.  Hysterical  patients  are  capable  of  developing  a  great 
variety  of  gastric  symptoms — loss  of  appetite,  perverted  appetite, 
distaste  for  food,  nausea,  vomiting,  pain,  and  flatulence. 

As  a  rule  these  patients  are  best  treated  if  we  disregard  the 
gastric  symptoms  and  employ  the  regular  management  for  hys- 
terical cases. 

8.  The  habitual  use  of  tobacco  and  of  alcohol  will,  in  some 
persons,  even  before  chronic  gastritis  is  produced,  cause  loss  of 
appetite,  nausea,  and  vomiting. 

9.  Neurasthenia.  Of  the  patients  w^ho  suffer  from  the  condi- 
tion of  neurasthenia  a  considerable  number  have  decided  gastric 
symptoms.  Generally  speaking  it  is  better  not  to  pay  too  much 
attention  to  the  stomach,  but  to  rely  on  baths,  massage,  exercise, 
climate,  etc.  I  see  neurasthenics,  however,  who  are  entirely  re- 
lieved by  lavage  of  the  stomach.  This  seems  to  be  a  simple  faith 
cure. 

Gastralgia. 

Pain  in  the  stomach  accompanies  an  excessive  production  of 
hyperacid  gastric  juice,  regurgitation  of  bile  into  the  stomach,  in- 
sufficient action  of  the  muscular  coat,  diseases  of  the  colon,  anae- 


178  THE   STOMACH. 

mia,  hysteria,  acute  gastritis,  chronic  gastritis,  ulcer  of  the  stomach 
and  cancer  of  the  stomach,  and  locomotor  ataxia.  It  is  closely 
simulated  by  the  pain  of  intestinal  colic,  by  the  pain  due  to  cal- 
culi in  the  gall-bladder  and  bile-ducts,  and  by  ulcers  of  the 
duodenum. 

In  some  cases  of  movable  kidney  the  patients  complain  of 
gastric  pain,  nausea,  and  vomiting. 

Whether,  in  addition,  gastralgia  occurs  as  a  pure  neurosis,  it 
is  difficult  to  say.  Probably  with  greater  accuracy  in  diagnosis 
the  apparent  number  of  such  cases  diminishes.  In  those  cases 
in  which  we  do  have  to  make  the  diagnosis  of  gastralgia  as  an 
independent  condition,  the  drugs  which  seem  to  be  of  ilie  most 
service  are  arsenic  or  quinine. 

Acute  Dilatation  of  the  Stomach. 

This  is  a  very  rare  condition.  I  copy  the  account  of  it  from 
Quain's  "  Dictionary  of  Medicine." 

The  earliest  case  on  record  is  that  of  a  lady  mentioned  in  the 
fourth  volume  of  the  "  Pathological  Transactions,"  by  Dr.  Miller 
and  Dr.  Humby.  She  had  been  under  treatment  for  piles  shortly 
before  her  illness,  and  the  abdomen  had  been  observed  to  have 
increased  in  size.  She  was  attacked  with  vomiting  of  immense 
quantities  of  fluid.  The  vomiting  ceased  four  days  afterward, 
and  the  abdomen  was  found  to  be  greatly  enlarged.  After  death 
the  cause  of  the  abdominal  distention  proved  to  be  the  stomach, 
which  was  so  much  dilated  that  it  was  capable  of  holding  ten 
pints  of  liquid.  Dr.  H.  Bennett,  of  Edinburgh,  relates  a  similar 
case,  and  attributes  the  dilatation  to  a  large  quantity  of  efferves- 
cing liquid  the  patient  had  swallowed  to  allay  his  thirst.  Dr. 
Hilton  Fagge,  in  the  "Guy's  Hospital  Reports"  (vol.  xviii., 
Third  Series),  describes  two  cases  that  had  fallen  under  his 
notice,  and  also  mentions  that  two  similar  cases  had  been  ob- 
served at  Guy's  Hospital  during  fourteen  years. 

Diagnosis. — The  signs  of  the  dilatation,  according  to  Dr.  Fagge, 
are  :  i.  A  rapidly  increasing  distention  of  the  abdomen,  which  is 
unsymmetrical,  the  left  hypochondrium  being  full,  while  the 
right  hypochondrium  is  comparatively  flattened.  2.  Tlie  exist- 
ence of  a  surface-marking  descending  obliquely  toward  the 
umbilicus  from  the  left  hypochondrium,  and  corresponding  with 
the  dragged-down  lesser  curvature  of  the  stomach,  this  line  ap- 


THE    STOMACH.  1 79 

pearing  to  descend  with  each  inspiration.  3.  Tlic  presence  of 
fluctuation  in  the  lower  part  of  the  abdomen.  4.  The  occurrence 
of  splasliing  wlien  the  distended  part  of  the  abdomen  is  manipu- 
lated. 5.  The  presence  of  a  uniformly  tympanitic  note  over  a 
large  part  of  the  distended  region  when  the  patient  lies  flat  on 
his  back.  Above  the  pubes,  on  the  other  hand,  there  may  be 
dulness  on  percussion  simulating  that  of  a  distended  bladder. 

The  treatment  is  to  empty  the  stomach  by  the  stomach-tube 
and  feed  the  patient  with  nutrient  enemata. 

Chronic  Dilatation  of  the  Stomach. 

For  clinical  purposes  it  is  convenient  to  describe  three  forms 
of  dilatation  of  the  stomach. 

1.  There  is  a  form  of  moderate  dilatation  of  the  stomach,  with- 
out stenosis  of  the  p3dorus,  without  chronic  gastritis,  without 
failure  of  stomach  digestion.  If  not  relieved  by  treatment  the 
condition  continues  for  years,  although  there  are  often  periods  of 
improvement.  The  two  prominent  symptoms  are  pain  in  the 
upper  part  of  the  abdominal  cavity  and  loss  of  nutrition.  The 
pain  comes  on  at  intervals,  which  become  shorter  and  shorter 
until  there  is  pain  every  day.  The  loss  of  flesh  and  strength  are 
progressive  until  the  patients  can  hardly  walk. 

With  these  two  cardinal  symptoms  are  often  associated  a 
variety  of  accessory  symptoms.  Some  patients  complain  of 
dyspnoea,  apparently  diaphragmatic  in  character.  In  some  the 
heart's  action  is  increased  in  frequency.  In  women  there  may 
be  a  variety  of  nervous  and  hysterical  symptoms.  The  loss  of 
nutrition  seems  to  depend  partly  on  insufficient  food,  for  the  pa- 
tients are  apt  to  leave  off  one  article  of  food  after  another  with 
the  idea  of  preventing  the  pain. 

Temporary  relief  may  be  obtained  by  travelling,  by  an  ex- 
clusive diet  of  milk  or  of  meat,  by  pepsine,  bismuth,  nux  vomica, 
etc.  But  tlie  symptoms  soon  return  and  grow  worse.  The  only 
curative  treatment  is  the  daily  lavage  of  the  stomach.  This  is 
very  effectual,  even  in  patients  who  have  suffered  for  a  number 
of  years. 

2.  There  is  a  form  of  dilatation  of  the  stomach  without 
stenosis  of  the  pylorus,  but  with  chronic  gastritis.  In  these 
cases  the  stomach  is  larger  and  articles  of  food  are  retained  in  it 
for  a  longer  time,  sometimes  for  several  days.     There  are  pains 


l80  THE    STOMACH." 

in  the  upper  part  of  the  abdominal  cavity  and  a  loss  of  flesh  and 
strength  which  is  carried  very  far.  Nausea  and  vomiting  are 
regularly  developed  after  a  time.  When  the  stomach  is  first 
washed  out,  even  after  twelve  hours'  abstinence  from  food,  it  will 
be  found  to  contain  a  large  quantity  of  undigested  material. 

These  patients  get  well  with  lavage,  but  it  has  to  be  kept  up 
for  a  long  time. 

3.  There  is  a  form  of  dilatation  with  stenosis  of  the  pylorus. 
The  stenosis  is  caused  by  carcinoma,  b}''  ulcers,  and  by  inflam- 
matory thickenings.  The  dilatations  produced  in  this  way  are 
very  large  and  much  food  is  retained.  Tlie  patients  have  pain, 
loss  of  nutrition,  nausea,  and  vomiting. 

The  patients  are  made  more  comfortable  and  life  is  prolonged 
by  lavage,  but  after  a  time  they  do  badly,  lose  flesh  and  strength 
and  die. 

The  surgical  procedures  usually  adopted  for  the  relief  of  the 
stenosis  are  :  resection  of  the  pylorus,  dilatation  of  the  pylorus, 
and  intestinal  anastomosis. 

Acute   Catarrhal   Gastritis. 

Lesions. — Tlie  changes  are  tlie  same  as  in  all  acute  catarrhal  in- 
flammations—  congestion,  swelling,  at  first  dryness,  later  an  in- 
creased production  of  mucus,  exudation  of  serum,  emigration  of 
white  blood-cells.  The  inflammation  may  involve  the  whole  of 
the  glandular  coat  of  the  stomach,  or  only  its  pyloric  portion  ;  it 
may  extend  to  the  duodenum. 

Causes. — The  disease  occurs  at  all  ages  and  in  both  sexes.  It 
may  occur  at  any  time  of  the  year,  but  is  especially  common  in 
summer.  It  is  apparently  sometimes  caused  by  atmospheric 
conditions.  It  frequently  complicates  the  exanthemata,  typhoid 
fever,  and  epidemic  influenza.  It  may  be  produced  by  unwhole- 
some and  irritating  food.  It  is  of  frequent  occurrence  in  per- 
sons who  have  fatty  degeneration  of  the  liver.  It  occurs  very 
often  as  a  primary  inflammation.  Some  persons  show  a 
marked  predisposition  to  the  disease,  and  suffer  from  repeated 
attacks.  This  is  especially  the  case  in  some  young  children. 
They  will  have  one  or  more  attacks  of  acute  gastritis  every  year 
for  several  years.  As  they  grow  older  the  attacks  are  less  fre- 
quent and  less  severe. 

Symptoms. — The  symptoms  of  an  acute  gastritis  may  come  on 


THE   STOMACH.  l8l 

suddenly  or  they  may  be  preceded  by  symptoms  of  gastric  indi- 
gestion, of  subacute  gastritis,  or  by  a  diminution  of  the  quan- 
tity of  bile  in  the  stools. 

Pain  is  often  complained  of.  It  may  be  a  severe  pain,  or 
only  a  feeling  of  soreness  or  of  discomfort. 

Vomiting  is  regularly  present.  It  is  in  proportion  to  the 
severity  of  the  gastritis,  and  is  most  troublesome  during  the  first 
days  of  the  inflammation.  The  patients  vomit  whatever  they 
take  into  the  stomach,  and  more  or  less  mucus  and  serum.  In  se- 
vere cases  large  numbers  of  pus-cells  and  some  red  blood-cells  are 
found  in  the  vomited  mucus  and  serum.  The  irritability  of  the 
stomach  may  be  so  great  that  neither  food  nor  medicine  can  be 
retained. 

A  rise  of  temperature  accompanies  the  first  days  of  the  inflam- 
mation in  some  patients,  but  in  many  there  is  not  at  any  time  a 
febrile  movement.  As  a  rule,  the  bowels  are  constipated.  But 
in  some  patients  an  acute  colitis  is  developed  at  the  same  time 
as  the  gastritis,  and  then  there  is  diarrhoea.  There  is  a  good 
deal  of  variety  as  to  the  length  and  severity  of  the  attacks,  the 
frequency  of  the  vomiting,  the  height  of  the  temperature,  and 
the  degree  of  the  prostration.  Attacks  of  acute  gastritis  are  not 
infrequently  followed  by  subacute  and  chronic  gastritis. 

Course  of  the  Disease. — (i)  In  infants  and  young  children  the 
vomiting  is  incessant,  and  excited  by  everything  which  is  taken 
into  the  stomach  ;  the  rise  of  temperature  is  often  well  marked, 
and  the  prostration  is  considerable.  The  gastritis  may  be  ac- 
companied with  or  followed  by  diarrhoea.  The  S3'mptoms  may 
last  only  for  a  few  days,  or  for  several  weeks.  Such  a  gastritis 
may  not  at  any  time  be  serious,  or  it  may  produce  a  prostration 
which  lasts  for  weeks,  or  it  may  be  fatal. 

(2)  Mild  cases  in  adults.  The  patients  are  not  at  any  time 
very  sick,  nor  is  there  a  rise  of  temperature.  There  are  loss  of 
appetite,  nausea  and  vomiting,  with  a  feeling  of  discomfort  or  of 
actual  pain  referred  to  the  stomach.  The  tongue  is  coated,  the 
bowels  may  be  constipated.  The  attack  usually  runs  its  course 
within  a  week  and  terminates  in  recovery,  but  the  inflammation 
may  pass  into  the  subacute  or  chronic  condition. 

(3)  Severe  gastritis  in  adults  is  attended  with  the  same  symp- 
toms, but  they  are  more  marked. 

The  patients  are  sick  enough  to  stay  in  bed,  in  some  the 
prostration  and  feeble   heart  action   are   alarming,   in  some  the 


1 82  THE    STOMACH. 

loss  of  flesh  and  strength  are  extreme.  A  febrile  movement  may 
be  present  or  absent.  The  feeling  of  nausea  is  constant,  the 
vomiting  frequent,  the  pain  and  discomfort  most  distressing. 
Even  a  severe  attack  may  run  its  course  within  a  week,  but  tlie 
attacks  often  last  much  longer,  and  may  be  succeeded  by  sub- 
acute or  chronic  gastritis. 

(4)  The  inflammation  involves  either  the  whole  stomach,  or 
the  pyloric  end  of  the  stomach,  the  duodenum,  and  the  common 
bile-duct.  The  patients  then  have  the  symptoms  described  under 
the  name  of  simple  jaundice. 

(5)  The  inflammation  is  confined  to  the  pyloric  end  of  the 
stomach  and  the  duodenum.  The  symptoms  are  the  same  as 
those  of  an  attack  of  simple  jaundice,  but  without  the  jaundice. 
The  patients  suffer  from  general  malaise,  headache,  dulness, 
drowsiness,  vertigo.  The  tongue  is  coated,  loss  of  appetite, 
nausea,  occasional  vomiting,  pain  in  the  epigastric  region  and 
sometimes  fever  are  present.  The  bowels  are  constipated  and 
the  faeces  light  colored. 

Treatment. — There  can  be  no  doubt  that  in  some  persons  acute 
gastritis  is  caused  by  hot  weather.  It  is  important  for  such  per- 
sons to  pass  their  summers  in  a  cool  climate. 

In  infants  gastritis  is  often  caused  by  the  food.  Not  that  the 
food  is  irritating  but  that  it  contains  pathogenic  bacteria  and 
the  products  of  their  growth.  This  is  an  additional  reason  for 
tlie  most  scrupulous  cleanliness  in  preparing  and  sterilizing  the 
food  of  children. 

In  any  case  of  acute  gastritis  it  is  well  to  keep  the  patient  in 
bed.  For  the  first  twenty-four  or  forty-eight  hours  the  irritabil- 
ity of  the  stomach  maybe  so  great  that  it  will  retain  nothing. 
When  this  is  the  case  it  is  wise  to  desist  altogether  from  giving 
food  or  medicine  by  the  mouth.  After  this  tlie  food  is  given  at 
first  by  the  teaspoonful  and  then  the  quantity  gradually  in- 
creased. The  best  foods  are  usually  cream  and  water,  koumyss, 
milk,  beef-tea,  beef-juice,  and  scraped  beef.  Rectal  enemata 
help  but  very  little  in  nourishing  these  patients. 

The  external  application  of  heat  over  the  upper  portion  of 
the  abdomen  by  fomentations,  hot-water  bags,  or  poultices  is 
grateful  to  the  patient. 

Of  drugs  the  sulphate  of  morphia  and  codeia  are  the  most 
valuable.  They  are  to  be  given  in  small  doses,  -^-^  to  \  grain  of 
morphia,  -^^  to  i  grain  of  codeia,  at  intervals  of  from  one  to  three 


THE   STOMACH.  183 

hours.  They  are  to  be  used  in  the  form  of  tablets,  wliich  dis- 
solve in  the  mouth,  or  given  hypodermically. 

The  hydrochlorate  of  cocaine  is  sometimes  of  use  for  aduks, 
one-tenth  grain  in  tablet  form  at  intervals  of  from  one  to  four 
hours. 

Ipecac  in  tablets  of  one-tentl.  grain  given  every  hour  may 
exert  a  specific  effect  on  the  gastritis.  The  oxalate  of  cerium 
and  bicarbonate  of  soda  are  useful  drugs,  they  are  best  given  in 
milk  or  in  cream  and  water.  A  good  formula  is  to  mix  together 
in  a  half-pint  measure  equal  parts  of  cream,  milk,  and  water,  add 
to  tliis  ten  grains  of  oxalate  of  cerium  and  twenty  grains  of  bi- 
carbonate of  soda  ;  give  a  teaspoonful  every  half  hour. 

When  the  gastritis  involves  the  pyloric  end  of  the  stomach, 
rectal  enemata  of  very  hot  or  very  cold  water,  and  purgation  by 
calomel  may  be  of  much  service. 

Chronic  Catarrhal  Gastritis. 

It  is  customary  to  include  several  different  lesions  of  the 
stomach  under  this  name. 

Lesions. — i.  The  only  evident  change  in  the  stomach  is  an 
increased  production  of  mucus.  This  can  be  washed  out  of  the 
stomach  during  life,  it  is  found  adherent  to  the  wall  of  the  stom- 
ach after  death. 

2.  Besides  the  increased  production  of  mucus  there  is  also 
degeneration  of  the  cells  of  the  peptic  glands. 

3.  There  is  a  growth  of  connective  tissue  betw^een  the  gastric 
tubules,  with  deformity  and  atrophy  of  the  tubules.  In  some 
cases  the  new  connective  tissue  forms  little  polypoid  tumors 
which  project  inward. 

4.  With  cardiac  disease  and  with  cirrhosis  of  the  liver  there 
may  be  a  well-marked  chronic  congestion  of  the  mucous  mem- 
brane. 

5.  There  may  be  hypertrophy  of  the  muscular  and  connective 
coats  at  the  pylorus  producing  stenosis,  and  with  this  there  is 
often  dilatation  of  the  stomach. 

6.  There  may  be  a  more  diffuse  hypertrophy  of  the  muscular 
and  connective-tissue  coats  with  marked  diminution  in  the  size 
of  the  stomach. 

7.  The  stomach  may  be  considerably  dilated  without  stenosis 
of  the  pylorus. 


I  84  THE   STOMACH. 

When  we  say  that  a  patient  has  chronic  catarrhal  gastritis  we 
mean  that  either  : 

The  mucous  glands  are  constantly  producing  too  much  mu- 
cus. 

Or  that  in  addition  the  functions  of  the  peptic  glands  are  dis- 
turbed. 

Or  that  the  structure  of  the  glandular  coat  is  so  impaired  by 
disease  that  gastric  digestion  is  seriously  interfered  with. 

Or  that  the  mucous  membrane  is  constantly  in  the  condition 
of  chronic  congestion. 

Or  that  from  stenosis  of  the  pylorus  or  relaxation  of  the  mus- 
cular coat,  food  is  retained  in  the  stomach. 

Or  that  the  stomach  is  dilated  or  contracted. 

Etiology. — A  considerable  number  of  cases  of  chronic  gastritis 
follow  acute  or  subacute  gastritis.  This  is  especially  true  of  the 
gastritis  which  complicates  epidemic  infiuenza,  typhoid  fever,  and 
so  many  of  the  infectious  diseases. 

Cardiac  disease,  pulmonary  emphysema,  and  cirrhosis  of  the 
liver  produce,  first,  chronic  congestion  and  then  chronic  gastritis. 

Pulmonary  phthisis,  chronic  nephritis,  and  gout  are  often  ac- 
companied by  chronic  gastritis. 

The  habitual  use  of  improper  food,  of  alcohol,  and  of  drugs 
are  ordinary  causes. 

The  same  climatic  conditions  which  predispose  to  chronic 
naso-pharyngeal  catarrh  and  to  chronic  bronchitis  have  the  like 
effect  as  regards  chronic  gastritis. 

Symptoms. — First  among  the  symptoms  comes  pain,  varying 
from  a  mere  feeling  of  oppression  and  discomfort  to  the  most 
severe  and  agonizing  pain.  The  pain  is  in  some  cases  due  to 
the  presence  of  food  in  the  stomach.  It  comes  on  at  first  only 
with  a  considerable  quantity  of  food,  but  later  even  small  frag- 
ments of  solid  food  or  spoonfuls  of  liquid  food  will  excite  it. 
Very  often  patients  learn  to  vomit  of  their  own  accord  in  order 
to  relieve  the  pain. 

In  some  persons  the  pain  seems  to  accompany  gastric  diges- 
tion and  to  cease  when  this  is  finished. 

In  some  cases  the  pain  seems  to  depend  on  hyperacidity  and 
hypersecretion  of  the  gastric  juice. 

With  alcoholic  gastritis  there  may  be  a  peculiar  feeling  of 
soreness  in  the  stomach,  which  is  commonly  called  heartburn. 

Then  there  are  many  cases  in  which  we  can  only  say  that  so 


THE   STOMACH.  1 85 

long  as  the  patients  have  gastritis  they  Imve  pain,  and  as  the 
gastritis  improves  so  does  the  pain. 

As  a  rule  the  pain  is  at  first  not  constant,  but  comes  on  in  at- 
tacks, which  become  more  frequent  and  of  longer  duration  as 
the  gastritis  progresses. 

It  is  often  difficult  to  distinguish  the  pain  of  chronic  gastritis 
from  that  belonging  to  ulcer  of  the  stomach,  ulcer  of  the  duode- 
num, biliary  calculi,  intestinal  colic,  movable  kidney,  disease  of 
the  uterus,  tubes,  and  ovaries,  anaemia,  liysteria,  and  neurasthenia. 

Nausea  and  vomiting  are  also  regular  symptoms.  The  nausea 
belongs  to  the  early  morning  hours,  but  may  persist  throughout 
the  day.  It  may  show  itself  as  a  disgust  for  food,  or  as  a  feeling 
of  anxiety  and  depression  of  spirits,  or  as  the  actual  sensation  of 
impending  vomiting. 

The  vomiting  is  most  frequently  a  vomiting  of  food,  either  in 
considerable  quantities,  or  vomiting  kept  up  so  long  as  the 
smallest  particle  of  food  is  left  in  the  stomach.  In  some  cases 
of  alcoholic  gastritis  the  stomach  empties  itself  about  an  hour 
after  nearly  every  meal. 

In  other  cases  large  quantities  of  brownish  fluid,  mixed  with 
mucus  and  food,  accumulate  in  the  stomach  and  are  vomited 
from  time  to  time.  This  is  especially  the  case  when  the  stomach 
is  dilated.  Regurgitation  of  an  acid  fluid  before  breakfast  in 
the  morning  is  especially  common  with  alcoholic  gastritis.  In  a 
few  cases  the  patients  will  vomit  nearly  every  day  as  much  as 
half  a  pint  of  pure  mucus. 

There  are  rare  cases  in  whicli  vomiting  is  kept  up  as  a  habit 
long  after  the  real  reasons  for  it  have  stopped. 

Vomiting  of  blood  may  occur  in  the  course  of  any  chronic 
gastritis,  but  is  much  more  likely  to  occur  if  cirrhosis  of  the 
liver,  or  fatty  liver,  exist  at  the  same  time.  Usually  the  hemor- 
rhages are  small,  but  with  cirrhosis  of  the  liver  large  quantities  of 
blood  are  coughed  up. 

The  vomiting  may  occur  in  attacks  with  intervals  of  days  or 
weeks,  or  it  comes  every  dav.  I  have  known  a  man  to  vomit 
every  day  for  twenty  years. 

Vomiting  is  also  caused  by  diseases  of  the  uterus,  tubes,  and 
ovaries,  by  an  accumulation  of  faeces  in  the  colon,  by  anaemia 
and  by  hysteria. 

Retention  of  food  in  the  stomach  is  especially  a  feature  when 
there  is  stenosis  of  the  pylorus  or  dilatation  of  the  stomach,  but 


1 86  THE   STOMACH. 

it  is  also  found  with  chronic  gastritis.     A  considerable  retention 
of  food  is  regularly  attended  with  vomiting. 

Constipation  is  often  present.  It  seems  to  depend  on  a  variety 
of  causes  and  may  have  nothing  to  do  with  the  condition  of  the 
stomach,  but  in  some  cases  as  the  gastritis  improves  the  bowels 
become  regular. 

Headache  is  often  a  symptom.  It  follows  a  variety  of  types, 
but  perhaps  the  most  common  is  that  which  comes  on  at  inter- 
vals. In  some  cases  it  is  found  that  whenever  there  is  headache 
bile  can  be  washed  out  of  the  stomach. 

A  general  loss  of  health,  of  which  emaciation  and  loss  of 
muscular  strength  are  the  most  prominent  features,  is  found 
with  the  more  severe  cases  of  gastritis.  This  depends  largely 
upon  the  gastritis  and  the  interference  with  digestion,  but  in 
some  cases  it  is  simply  due  to  starvation.  Of  their  own  accord, 
or  by  the  advice  of  a  physician,  they  give  up  one  article  of  food 
after  another  until  they  do  not  get  enough  to  eat.  The  exclusive 
diet  of  meat  and  hot  water,  if  kept  up  for  too  long  a  time,  has  a 
particularly  bad  effect. 

A  considerable  number  of  nervous  and  hysterical  symptoms, 
and  disturbances  of  sensation  in  the  mouth,  throat,  and  other 
parts  of  the  body  are  often  present.  It  is  difficult  to  tell  how 
far  these  symptoms  are  to  be  attributed  to  the  gastritis. 

Course  of  the  Disease. — Chronic  gastritis  seems  to  have  a  natu- 
ral disposition  to  continue  and  to  grow  worse  from  year  to  year, 
but  with  periods  of  remission  and  exacerbation.  The  histories, 
therefore,  may  extend  over  many  years,  and  the  symptoms  come 
on  in  attacks.  Between  the  attacks  the  patients  seem  to  be  well, 
but  the  attacks  become  more  severe,  of  longer  duration,  and  oc- 
cur at  shorter  intervals,  as  the  disease  goes  on, 

I  do  not  know  of  any  satisfactory  way  of  classifying  the  varie- 
ties of  chronic  gastritis.  We  can,  however,  for  practical  pur- 
poses, put  the  patients  together  in  rather  rough  groups. 

I.  The  cases  in  which  pain  referred  to  the  region  of  the  stom- 
ach is  the  principal  symptom. 

(a.)  Pain  without  vomiting  occurs  witli  chronic  gastritis  by 
itself,  or  with  retention  of  food,  or  with  dilatation  of  the  stomach, 
or  with  failure  of  gastric  digestion.  The  patients  do  not  distin- 
guish between  these  conditions,  they  only  complain  of  the  pain, 
they  often  do  not  think  that  they  have  any  stomach  disease.  The 
diao-nosis  has  to  be  made  with  the  stomach-tube. 


THE   STOMACH.  I  8; 

(b.)  Pain  with  vomiting  occurs  with  hypcracidily,  with  dilata- 
tion, and  with  abnormal  sensitiveness  of  the  gastric  mucous  mem- 
brane to  the  contact  of  food.  The  last  condition  seems  to  give 
the  most  intense  gastric  pain  there  is,  a  pain  that  can  only  be  re- 
lieved by  the  removal  of  the  food  from  the  stomach. 

2.  Nausea  and  vomiting  are  ordinary  symptoms  in  all  the 
forms  of  chronic  gastritis,  but  there  are  some  patients  in  whom 
they  are  particularly  prominent.  There  are  persons  in  whom  for 
many  years  nausea,  with  the  accompanying  depression  (;f  spirits, 
in  the  early  morning,  is  the  only  symptom  for  many  years. 
There  are  persons  in  whom  vomiting,  with  or  without  nausea, 
continues  for  years,  and  yet  there  are  no  other  gastric  symp- 
toms. 

3.  There  are  patients  who  for  3'ears  suffer  from  attacks  of 
sick-headache,  witii  or  without  vomiting.  Later,  instead  of  the 
sick-headaches,  there  are  attacks  of  gastric  pain  and  vomiting. 

In  some  of  the  cases  bile  can  be  washed  out  of  the  stomach 
during  every  attack,  in  others  no  bile  is  present. 

4.  There  are  patients  who  suffer  from  retention  of  food  in 
the  stomach,  or  from  dilatation  without  stenosis  in  addition  to  the 
chronic  gastritis.  Pain  and  loss  of  nutrition  are  the  prominent 
symptoms.     Treatment  is  often  very  satisfactory. 

5.  In  the  patients  with  dilatation  and  stenosis  of  the  pylorus 
the  pain,  vomiting,  and  loss  of  nutrition  get  steadily  worse. 
Treatment  only  relieves  the  pain  and  vomiting,  the  loss  of  nutri- 
tion continues.  The  question  of  a  surgical  operation  regularly 
comes  up. 

6.  Tliere  are  patients  in  whom  depression  of  spirits  going  on 
to  actual  melancholia  is  the  most  niarked  symptom.  In  these 
cases  as  the  gastritis  improves  the  melancholia  disappears.  Of 
course  a  great  many  of  the  cases  of  melancholia  do  not  have 
gastritis  at  all. 

7.  There  are  patients  in  whom  the  loss  of  nutrition  is  out  ol 
proportion  to  the  gastric  symptoms.  They  really  have  a  chronic 
gastritis,  but  it  may  be  difficult  to  tell  how  far  this  is  the  cause 
of  the  loss  of  nutrition,  and  how  far  it  is  the  thing  to  be  treated. 
Some  of  these  cases  are  very  difficult  to  manage. 

Treatment. — In  attempting  to  establish  a  satisfactory  treatment 
for  chronic  gastritis,  it  is  important  to  state  as  clearly  as  possible 
the  problem  which  is  to  be  solved. 

First,  then,  we  must  remember  that  all  the  patients  who  suf- 


1 88  THE   STOMACH. 

fer  from  gastric  symptoms  do  not  necessarily  have  chronic  gas- 
tritis. 

Besides  those  wlio  have  functional  disturbance  of  the  stomach, 
or  cancer  or  ulcer  of  the  stomach,  we  find  many  others  in  whom 
gastric  symptoms  are  due  to  diseases  of  other  parts  of  the  body. 
Anaemia,  uterine  disease,  the  neurotic  and  hysterical  condition, 
and  constipation,  often  behave  in  this  way.  In  old  people  the 
function  of  gastric  digestion  is  often  impaired  simply  as  the  re- 
sult of  old  age.  To  each  one  of  these  conditions  belongs  its  ap- 
propriate treatment,  but  it  is  not  the  treatment  of  chronic 
gastritis. 

Still  further,  we  must  remember  that  in  many  cases  of  gas- 
tritis palliation  of  the  symptoms  is  all  that  we  can  hope  for. 
This  is  true  with  the  gastritis  associated  with  heart  disease,  em- 
physema, phthisis,  cirrhosis,  Bright's  disease,  gout,  rheumatism, 
and  alcoholism.  It  is  also  true  of  the  cases  in  which  the  inflam- 
mation has  gone  on  to  the  destruction  of  the  peptic  and  mucous 
glands.  After  excluding  all  these,  there  remains  a  large  and  im- 
portant group  of  cases  of  chronic  catarrhal  gastritis,  in  which  we 
may  hope  not  only  to  alleviate  the  symptoms,  but  to  cure  the 
disease. 

It  is  evident,  from  the  nature  of  the  disease,  that  any  treat- 
ment intended  not  merely  to  palliate,  but  to  cure,  must  be  of 
long  duration,  and  that  it  must  be  repeated  from  time  to  time, 
when  the  inevitable  relapses  occur. 

The  different  plans  of  treatment,  then,  which  maybe  adopted 
are: 

The  curative  effects  of  climate  and  mode  of  life. 

The  regulation  of  the  diet. 

The  administration  of  drugs. 

The  use  of  local  applications  directly  to  the  inflamed  mem- 
brane. 

It  is  unnecessary  to  lay  down  rules  as  to  the  sort  of  climate, 
that  can  be  regulated  by  the  tastes  of  the  patient.  The  two 
points  of  importance  are  :  First,  the  locality  selected  must  be 
one  where  the  patient  can  lead  an  out-door  life.  Second,  the 
patient  must  live  in  this  climate  either  for  several  years,  or  for  a 
considerable  part  of  each  year. 

Excellent  as  this  method  of  treatment  is,  it  is  evident  that  it 
can  be  carried  out  only  by  a  limited  number  of  persons. 

The  reo-ulation  of  the  diet  is  a  matter  which  demands  consid- 


THE   STOMACH.  '  189 

eration  in  every  case  of  chronic  gastritis.  In  trying  to  ascertain 
the  best  way  of  feeding  tiiese  patients,  I  liave  found  only  one  sat- 
isfactory method,  and  that  is  to  feed  tlieni  experimentally  with 
different  articles  of  food,  and  then  after  an  interval  of  several 
hours  wash  out  the  stomach  and  see  how  thoroughly  these  arti- 
cles of  food  have  been  digested  and  removed  from  the  stomach. 
After  pursuing  tliis  course  for  a  number  of  years  I  have  arrived 
at  the  following  conclusions  : 

It  is  necessary  that  the  patient  should  be  well  fed,  a  starva- 
tion diet  never  answers. 

The  stomach  does  not  require  any  rest  from  the  performance 
of  stomach  digestion  ;  on  the  contrary,  it  is  all  the  better  for 
being  called  on  to  perform  its  natural  functions. 

The  patients'  own  ideas  as  to  what  food  agrees  with  them  are 
usually  erroneous.  They  are  apt  either  to  starve  themselves  or 
to  select  the  least  nutritious  articles  of  food. 

The  use  of  artificially  digested  foods,  or  of  substances,  such  as 
pepsine,  to  assist  stomach  digestion  is  unnecessary. 

The  starches,  oatmeal,  corn-m.eal,  bread,  the  cereals,  the 
health  foods  are,  as  a  rule,  bad.  Portions  of  them  remain  undi- 
gested in  the  stomach  for  many  hours. 

Milk  in  adults  is  an  uncertain  article.  It  answers  very  well 
for  some  persons,  not  at  all  for  others. 

Meat  is  usually  readily  and  well  digested,  but  there  are  oc- 
casional exceptions  to  this  rule. 

Vegetables  and  fruits  can  be  eaten,  but  the  particular  varie- 
ties must  be  selected  experimentally  for  each  patient. 

I  do  not  believe  that  any  case  of  chronic  gastritis  is  to  be 
cured  by  diet  alone.  Even  the  exclusive  milk  diet,  while  it  often 
relieves  symptoms,  is,  as  a  rule,  only  temporary  in  its  effects,  so 
that  the  patient  simply  loses  a  certain  amount  of  time  by  em- 
ploying this  instead  of  more  efficacious  plans  of  treatment. 

The  advantageous  use  of  drugs  belongs  to  the  earlier  stages 
of  chronic  gastritis.  At  that  time  they  often  palliate  symptoms 
and  sometimes  even  seem  to  cure  the  inflammation.  In  the  later 
stages  of  the  disease  their  use  becomes  more  and  more  unavail- 
ing. The  reliable  drugs  for  this  purpose  are  not  numerous  :  the 
preparations  of  soda,  potash,  and  bismuth,  the  mineral  acids, 
glycerine,  sometimes  carbolic  acid,  sometimes  iodoform,  some- 
times the  bitter  infusions.  If  none  of  these  answer,  it  is  hardly 
worth  while   to   look  any   further.     If  we  can  combine,  with  the 


IQO  THE   STOMACH. 

administration  of  di  ugs,  tlie  regulation  of  the  diet,  and  of  the 
mode  of  life  of  the  patient,  then  of  course,  our  chances  of  suc- 
cess are  much  greater. 

THE    USE    OF    LOCAL    APPLICATIONS    DIRECTLY    TO    THE    GLANDULAR 
COAT    OF    THE    STOMACH. 

This  I  regard  as  the  most  efficacious  plan  of  treatment  for 
those  patients  who  are  not  able  to  leave  home  and  seek  a  proper 
climate,  but  ask  to  be  relieved  without  interruption  to  tiieir  or- 
dinary pursuits.  The  local  applications  are  readily  made  by  the 
introduction  of  a  soft  rubber-tube  through  the  oesophagus  into 
the  stomach. 

Liquid  applications  are  the  best.  They  should  be  made  in 
such  quantities  as  to  come  thoroughly  into  contact  with  the  en- 
tire surface  of  the  mucous  membrane,  although  the  pyloric  end  of 
the  stomach  is  the  region  where  the  inflammation  is  principally 
situated.  They  should  be  made  at  a  time  long  enough  after  eat- 
ing for  the  stomach  to  be  as  nearly  empty  as  possible. 

For  many  cases  warm  water  alone  in  considerable  quantities 
is  the  only  local  application  needed.  In  some,  however,  there  is 
an  advantage  in  medicating  the  water,  and  for  this  purpose  I 
employ  a  variety  of  substances. 

The  alkalies,  the  mineral  acids,  bismuth,  carbolic  acid,  the 
salicylates,  iodoform,  belladonna,  ipecac,  gelseminum,  may  each 
one  be  employed  according  to  the  particular  case. 

For  the  first  week  it  is  often  necessary  to  put  the  patient  on 
a  milk  diet,  and  this  can  be  done  even  with  those  patients  who 
under  ordinary  circumstances  cannot  take  milk  at  all. 

Then,  after  a  time,  to  the  milk  we  add  one  solid  meal  com- 
posed of  meat  alone.  Next,  this  single  meal  is  increased  by  the 
gradual  addition  of  fruits,  vegetables,  and  bread.  Then  comes 
the  giving  of  two  solid  meals  a  day,  instead  of  one,  then  three 
solid  meals,  and  now  we  get  rid  of  the  milk  in  part  or  altogether. 

For  the  first  week  of  this  treatment  it  is  wise  not  to  expect 
any  special  improvement.  Indeed,  even  a  longer  time  than  this 
may  try  the  perseverance  of  the  physician  and  the  confidence  of 
the  patient. 

Sooner  or  later,  however,  the  expected  improvement  begins  : 
the  nausea  and  vomiting  cease,  the  constipation  or  diarrhoea  is 
improved  ;  the  flatulence  is  no   longer  troublesome  ;  the  head- 


THE   STOMACH.  I9I 

ache  becomes  less  frequent  ;  and,  of  more  real  value  tlian  these, 
the  improvement  in  the  general  condition  of  tlie  patient  becomes 
evident.  The  color,  the  weight,  the  appetite,  the  sleep,  the 
spirits  of  the  patient,  all  show  a  change  for  the  better.  Of  all 
the  symptoms,  the  pain  is  tlie  one  which  is  apt  to  persist  the 
longest. 

For  two  or  three  months  the  patient  has  to  be  kept  under 
observation,  and  tlie  applications  to  the  stomach  made  by  the 
physician.  After  tliis  the  patient  is  dismissed,  but  continues  the 
treatment  himself,  first  every  other  day,  then  twice  a  week,  then 
once  a  week  for  several  months.  The  regular  relapses  of  the  dis- 
ease are  managed  in  the  same  way,  but  are  much  more  quickly 
relieved. 

Suppurative  Gastritis. 

Lesions. — There  is  a  suppurative  inflammation  beginning  in 
the  connective-tissue  coat  of  the  stomach,  and  extending  to  the 
other  coats.  This  inflammation  may  be  circumscribed,  with  the 
formation  of  an  abscess  ;  or  diffuse,  with  a  purulent  infiltration 
of  the  entire  connective-tissue  coat.  The  abscesses  may  rupture 
into  the  cavity  of  the  stomach.  The  inflammation  of  the  perito- 
neal coat  may  give  ris.e  to  a  general  peritonitis. 

Causes. — The  disease  belongs  to  adult  life.  It  is  more  com- 
mon in  males  than  in  females.  There  is,  in  some  cases,  a  history 
of  the  over-eating  of  indigestible  food.  It  evidently  belongs  to 
the  class  of  infectious  inflammations. 

Symptoms. — The  formation  of  the  abscesses  in  the  wall  of  the 
stomach  is  attended  with  pain  in  the  epigastric  region,  vomiting, 
a  febrile  movement,  and  the  formation  of  a  tumor.  If  the  ab- 
scess ruptures  into  the  stomach,  the  pus  may  be  vomited.  The 
peritonitis  often  remains  localized.  The  disease  may  run  an 
acute  or  a  chronic  course. 

The  diffuse  suppurative  inflammation  of  the  wall  of  the 
stomach  runs  an  acute  course,  terminating  fatally  in  from  three  to 
eighteen  days.  The  patient  is  suddenly  attacked  with  vomiting, 
pain,  and  tenderness  over  the  stomach,  fever,  and  great  prostra- 
tion. The  symptoms  of  general  peritonitis  are  soon  added,  and 
the  patients  rapidly  get  worse. 

Treatment. — The  best  that  we  can  do  seems  to  be  to  alleviate 
the  patient's  symptoms  by  the  liberal  use  of  opium. 


192  THE    STOMACH. 


Ulcer  of  the  Stomach. 

Lesions. — Ulcers  of  the  stomach  are  usually  single,  but  two  or 
more  ulcers  may  be  formed  at  the  same  time,  or  successively. 

Welch,  from  a  collection  of  793  cases,  gives  the  position  of 
such  ulcers  as  follows  : 

On  the  lesser  curvature,  288. 

On  the  posterior  wall,  235. 

At  the  pylorus,  95. 

On  the  anterior  wall,  69. 

At  the  oesophageal  end,  50. 

At  the  fundus,  29. 

On  the  greater  curvature,  27. 

The  ordinary  diameter  of  these  ulcers  is  from  half  an  inch  to 
two  inches,  but  some  are  very  small,  and  some  are  much  larger. 
Two  or  more  ulcers  may  become  joined,  and  so  form  a  large  ul- 
cerated area. 

The  ulcers  are  round  or  oval,  largest  in  the  glandular  coat. 
They  may  destroy  only  the  glandular  coat,  or  the  entire  thick- 
ness of  the  wall  of  the  stomach.  The  edges  of  the  ulcers  are 
clean  cut,  and  their  floors  smooth  ;  but  sometimes  the  edges  are 
■much  thickened,  and  the  floor  may  be  formed  by  tissues  whicii 
have  become  adherent.  The  edges  and  the  floor  are  formed  of 
amorphous  granular  matter,  or  of  connective  tissue. 

If  the  patients  recover,  the  ulcers  cicatrize  either  with  or 
without  deformity  of  the  stomach. 

If  the  ulcers  perforate  the  wall  of  the  stomach,  this  perfora- 
tion may  be  large  and  sudden,  with  the  escape  of  the  contents  of 
the  stomach  into  the  abdominal  cavity  ;  or  the  perforation  may 
be  small,  and  set  up  a  localized  peritonitis  ;  or  the  opening  may 
be  entirely  closed  by  adhesions. 

The  ulcer  may  erode  either  the  arteries  or  the  veins  of  the 
stomach.     With  an  ulcer  there  is  more  or  less  chronic  gastritis. 

Causes. — These  ulcers  are  said  to  be  twice  as  common  in  wom- 
en as  in  men.  Tliey  have  been  observed  at  nearly  every  age, 
but  seven  tenths  of  them  are  in  people  between  twenty  and  forty 
years  of  age. 

The  ordinary  explanation  of  the  way  in  which  these  ulcers 
are  formed  is,  that  by  embolism,  thrombosis,  or  chronic  endar- 
teritis one  of  the  branches  of  the  gastric  artery  is  occluded.     The 


THE   STOMACH.  I93 

corresponding  portion  of  the  wall  of  the  stomacli  dies  and  is 
destroj^ed  by  the  action  of  the  gastric  juice. 

Symptoms. — Of  all  t!ic  symptoms  pain  is  the  most  constant,  it 
is  absent  only  in  exceptional  cases,  it  varies  in  its  quality,  its  in- 
tensity, its  situation,  and  its  duration. 

The  most  characteristic  pain  is  severe  paroxysmal  pain  local- 
ized in  a  circumscribed  spot  in  the  epigastrium,  coming  on 
soon  after  eating  and  disappearing  when  the  stomach  is  emptied. 
Of  more  common  occurrence  are  paroxysms  of  severe  pain  dif- 
fused over  the  epigastrium  and  radiating  in  different  directions. 
In  many  cases  both  these  forms  of  pain  exist.  In  the  intervals 
between  the  paroxysms  of  pain  there  is  often  a  more  or  less  con- 
stant dull  pain  or  feeling  of  discomfort  at  the  epigastrium.  The 
position  of  the  pain  is  usually  at  or  a  little  below  the  ensiform 
cartilage.  It  may,  however,  be  felt  as  low  as  the  umbilicus,  or 
on  either  side  in  the  hypochrondriac  regions. 

The  pain  usually  comes  on  within  half  an  hour  of  taking  food 
and  continues  until  the  stomach  is  emptied  by  vomiting  or  by 
the  passage  of  food  into  the  duodenum. 

The  pain  is  regularly  increased  by  pressure  over  the  stomach, 
by  fatigue,  and  by  exposure.  It  is  diminished  by  rest  and  the 
recumbent  position.  The  pain  may  recur  at  regular  intervals,  it 
may  stop  altogether  for  days  or  weeks. 

Besides  the  pain  belonging  to  the  gastric  ulcer  the  patients 
may  also  have  pain  due  to  chronic  gastritis,  to  hyperacidity,  to 
retention  of  food,  to  dilatation  of  the  stomach,  or  to  localized 
peritonitis. 

Next  to  pain,  vomiting  is  the  most  frequent  symptom  of 
gastric  ulcer.  It  is  apt  to  occur  soon  after  taking  food,  or  after 
an  attack  of  gastric  pain.  The  patients  may  only  vomit  occasion- 
ally, or  every  day,  or  very  frequently.  In  some  cases  the  irrita- 
bility of  the  stomach  is  so  great  that  no  food  can  be  retained, 
and  the  effort  at  vomiting  will  be  made  even  when  the  stomach 
is  entirely  empty.  The  vomiting  seems  to  be  due  partly  to  the 
ulcer,  partl}^  to  the  accompanying  chronic  gastritis. 

It  is  estimated  that  vomiting  of  blood  occurs  in  about  one- 
third  of  the  cases  of  gastric  ulcer.  This  estimation  is  not  of 
much  value,  on  account  of  the  occurrence  of  vomiting  of  blood, 
with  chronic  gastritis  and  simple  anaemia. 

The  bleeding  may  be  preceded  by  pain,  vomiting,  and  dis- 
turbances of  digestion,  or  it  may  come  on  suddenly  without  any 


194  THE   STOMACH. 

other  gastric  symptoms.  The  quantity  of  blood  lost  may  be 
small,  or  large,  the  larger  hemorrhages  are  those  which  are  most 
characteristic  of  gastric  ulcer.  The  most  important  bleedings 
are  those  which  are  due  to  the  erosion  of  a  blood-vessel  in  the 
floor  of  the  ulcer.  The  blood  may  be  entirely  vomited,  or  some 
of  it  may  pass  into  the  intestine  and  be  discharged  with  the 
stools.  With  small  bleedings  all  the  blood  may  pass  into  the 
intestine,  none  of  it  being  vomited.  Rarely  the  patients  die  sud- 
denly without  any  vomiting,  and  at  the  autopsy  the  stomach  is 
found  to  be  full  of  blood. 

It  is  not  generally  understood  that  patients  with  either  per- 
nicious or  simple  anaemia  may  vomit  large  quantities  of  blood, 
and  even  bleed  to  death  without  any  ulcer  or  erosion  of  the 
stomach.  Such  large  bleedings,  due  to  anaemia,  and  not  to  ulcer 
of  the  stomach,  are  of  frequent  occurrence  and  yet  are  recognized 
by  few  physicians. 

The  importance  of  a  correct  diagnosis  is  very  great.  If  the 
bleeding  is  due  to  anaemia  and  the  patients  are  treated  for  ulcer 
of  the  stomach  they  are  very  apt  to  die.  If,  on  the  other  hand, 
it  is  appreciated  that  they  have  no  stomach  lesion,  and  they  are 
treated  for  anaemia  they  usually  recover. 

It  is  to  be  remembered  in  this  connection  that  many  anaemic 
patients  have  pain  after  eating,  nausea,  and  vomiting  without 
any  disease  of  the  stomach. 

Any  of  the  symptoms  which  have  been  described  under  the 
heads  of  functional  disorders  of  the  stomach  and  chronic  gastritis 
may  occur  in  cases  of  gastric  ulcer. 

The  frequency  of  perforation  of  the  ulcers  is  variously  stated 
by  different  authors.  Welch  gives  it  as  six  and  one-half  per 
cent,  of  all  cases  of  gastric  ulcer. 

It  is  said  that  perforation  occurs  two  or  three  times  oftener 
in  the  female  than  in  the  male,  and  that  in  the  female  the  liabil- 
ity is  greatest  between  fourteen  and  thirty  years  of  age.  In  the 
male  there  seems  to  be  no  greater  liability  to  perforation  at  one 
age  than  at  another.  Ulcers  of  the  anterior  wall  of  the  stomach 
perforate  more  frequently  than  those  in  other  situations.  The 
perforation  may  be  preceded  by  the  characteristic  pain  and 
vomiting  of  gastric  ulcer,  or  only  by  indefinite  gastric  symptoms, 
or  it  may  occur  suddenly  in  a  person  who  is  apparently  perfectly 
well. 

If  the  perforation   is  such  that   the   contents  of  the  stomach 


THE   STOMACH.  195 

escape  into  the  peritoneal  cavity  there  is  at  once  a  severe  pain 
and  the  patients  pass  into  the  condition  of  collapse.  If  they 
survive  the  slioclv  of  tlie  perforation  an  acute  general  peritonitis 
is  developed  wliich  is  regularly  fatal. 

The  perforation  may  be  small  and  limited  by  adhesions. 
Tlien  a  localized  peritonitis  with  collections  of  pus  is  set  up 
around  the  perforation.  In  this  way  are  formed  the  subphrenic 
abscesses  which  perforate  the  diaphragm  and  simulate  empyema 
or  pyopneumothorax. 

The  Course  of  the  Disease.— T\\&xq  may  be  no  symptoms  during 
life,  and  the  ulcer,  or  its  cicatrix,  is  found  after  death  from  some 
other  disease. 

There  are  cases  which  last  for  weeks,  months,  or  years.  The 
symptoms  are  marked,  but  more  or  less  severe.  Some  of  tlie 
patients  recover,  others  die  of  starvation. 

There  are  cases  in  which  one  or  more  large  hemorrhages 
form  the  prominent,  and  sometimes  the  only,  symptom. 

Tliere  are  cases  in  which  the  large  or  small  perforation  of  the 
wall  of  the  stomach  forms  the  prominent  feature. 

There  are  cases  in  which  the  deformity  of  the  stomach,  pro- 
duced by  the  cicatrization  of  the  ulcer,  gives  S3miptoms  for  the 
rest  of  the  patient's  life. 

Terminations. — In  the  majority  of  cases  gastric  ulcer  termi- 
nates in  recovery,  and  such  a  recovery  may  be  complete.  But  it 
may  happen  that  chronic  gastritis  or  deformities  will  be  left  be- 
hind which  give  troublesome  symptoms  for  many  years.  In  the 
fatal  cases  death  is  due  to  perforation,  to  hemorrhage,  or  to 
starvation  from  the  inability  of  the  stomach  to  retain  any  food. 

Treatment. — The  first  point  is  to  determine  whether  the  pa- 
tients can  be  fed  by  the  stomach  or  by  the  rectum. 

If  they  can  be  fed  by  the  mouth  we  give,  in  moderate  quan- 
tities and  at  regular  intervals,  milk,  peptonized  milk,  a  mixture 
of  equal  parts  of  milk,  cream,  and  water,  beef-juice,  or  Leube's  or 
Rudisch's  prepared  beef. 

If  they  have  to  be  fed  by  the  rectum,  this  is  washed  out  once 
a  day  witli  warm  water,  and  the  nutrient  enemata  are  given  once 
in  four  hours.  The  quantity  of  each  enema  should  be  four 
ounces.  They  may  be  composed  of  peptonized  milk,  defibri- 
nated  blood,  Leube's  beef  solution,  the  yolk  of  eggs,  cream, 
cod-liver  oil,  or  beef-juice.  There  may  be  an  advantage  in  add- 
ing brandy  or  opium  to  the  enema. 


196 


THE   STOMACH. 


The  drugs  ordinarily  employed  are  :  The  alkalies,  the  arti- 
ficial Carlsbad  salt  (sodium  sulphate,  5  parts;  sodium  bicarbo- 
nate, 2  parts  ;  sodium  chloride,  i  part ;  a  teaspoonful  in  half  a 
pint  of  hot  water  every  morning),  bismuth,  cocaine,  oxalate  of 
cerium,  nitrate  of  silver,  iodoform,  hydrocyanic  acid,  and  opium. 

In  any  case  of  suspected  ulcer  of  the  stomach  with  vomiting 
of  blood,  if  the  haemoglobim  is  less  than  fifty  per  cent.,  and  the 
red  blood-cells  less  than  2,000,000  to  the  cubic  millimetre,  it  is 
better  to  treat  the  anaemia  than  the  ulcer  of  the  stomach. 

Cancer  of  the  Stomach. 

Lesions. — The  new  growth  follows  the  anatomical  types  of 
colloid  cancer,  of  cancer  with  cylindrical  epithelial  cells,  and  of 
cancer  with  small  polygonal  cells.  The  growth  seems  to  origi- 
nate in  the  glandular  coat. 

The  most  common  shape  for  the  new  growth  to  take  is  that 
of  a  flattened  tumor  with  necrotic  and  ulcerating  centre  which 
projects  inward  into  the  cavity  of  the  stomach.  Instead  of  this, 
however,  the  tumor  may  be  quite  large  and  of  polypoid  shape. 
In  still  other  cases  there  is  no  tumor,  but  a  flat  infiltration  which 
occupies  more  or  less  of  the  wall  of  the  stomach.  There  is 
usually  more  or  less  chronic  catarrhal  inflammation  of  the  glan- 
dular coat.  The  peritoneal  coat  is  often  thickened  and  adherent 
to  the  surrounding  viscera.  The  process  of  ulceration  may  in- 
volve not  only  the  new  growth,  but  also  the  wall  of  the  stomach 
and  even  extend  into  the  adherent  viscera. 

While  the  great  majority  of  cancers  of  the  stomach  are  primary, 
yet  secondary  tumors  have  also  been  observed.  Welch  has  col- 
lected 37  such  cases,  17  secondary  to  cancer  of  the  breast,  8  to 
cancer  of  the  oesophagus,  3  to  cancer  of  the  mouth  or  nose,  and 
the  remainder  to  cancer  of  other  parts  of  the  body. 

Cancer  of  the  stomach  is  very  often  attended  with  the  growth 
of  metastatic  tumors  in  other  parts  of  the  body.  Welch  gives 
the  foUovving  table,  based  on  1,574  cases  : 


Lymphatic 
Glands. 

Liver. 

Peritoneum, 
Omentum, 
Intestine. 

Pancreas. 

Pleura 

and  Lung. 

Spleen. 

Brain. 

Other 
parts  of 
the  body. 

SSI 
35  P.c. 

475 
30.2  p.c. 

357 
22.7  p.c. 

122 
7.8  p.c. 

98 
6.2  p.c. 

26 
1.7  p.c. 

9 
0.6  p.c. 

92 
S.8  p.c. 

THE   STOMACH.  1 97 

Causes. — The  disease  is  equally  common  in  males  and  females. 
The  maximum  liability  to  the  disease  is  between  the  ages  of  60 
and  70  years,  but  gastric  cancer  is  common  enough  after  the 
age  of  forty,  and  is  even  occasionally  seen  in  persons  not  over  20 
years  old. 

Symptoms. — The  appetite  as  a  rule  is  poor,  either  because  the 
ingestion  of  food  causes  pain  or  nausea,  or  because  there  is 
actual  distaste  for  food.  But  there  are  exceptional  cases  in 
which  the  appetite  continues  to  be  very  good. 

Nausea  and  vomiting  are  often  present.  The  vomiting  is  of 
food,  of  brownish  or  yellow  fluid,  of  coffee-ground  matter,  or 
of  blood.  The  vomited  matters  may  have  an  offensive  odor. 
This  foul  smell  is  more  constant  in  the  contents  of  the  stomach 
when  they  are  washed  out  than  when  they  are  vomited.  When 
the  stomach  is  dilated  from  stenosis  of  the  pylorus  the  quantity 
of  vomit  at  one  time  is  often  very  large.  The  vomiting  may  be 
an  early  symptom  and  continue  throughout  the  disease.  Or  it 
may  not  come  on  until  the  disease  is  far  advanced.  Or  the 
vomiting  may  accompany  the  early  stages  of  the  growth  and  then 
stop,  not  to  begin  again.  In  a  moderate  number  of  cases  there 
is  no  vomiting  at  any  time,  this  may  be  the  case  even  when  there 
is  stenosis  of  the  pylorus. 

It  is  said  that  the  situation  of  the  cancer  exerts  great  influ- 
ence upon  the  frequency  of  vomiting,  and  the  time  of  its  occur- 
rence after  meals ;  that  when  the  cancer  involves  the  pyloric 
orifice,  vom.iting  is  rarely  absent,  and  generally  occurs  an  hour 
or  more  after  a  meal.  As  the  stomach  becomes  dilated  the 
vomiting  comes  on  longer  after  a  meal,  sometimes  not  until  after 
one  or  more  days.  Next  to  pyloric  cancer  it  is  cancer  involving 
the  cardiac  orifice  which  is  most  frequently  accompanied  by 
vomiting.  Here  the  vomiting  occurs  immediately  after  taking 
food.  If  there  is  stenosis  of  the  cardiac  orifice  the  food  is  regur- 
gitated.. When  the  cancer  is  situated  in  other  parts  of  the 
stomach  and  does  not  obstruct  the  orifices,  vomiting  is  more  fre- 
quently absent.  There  are  a  great  many  exceptions  to  these 
rules,  so  many  that  the  rules  themselves  are  not  of  much  practi- 
cal importance. 

Bleeding  from  cancers  of  the  stomacli  is  usually  in  small 
quantities,  and  the  blood  remains  in  the  stomach  long  enough 
to  be  changed  into  coffee-ground  matter,  but  sometimes  there 
are  very  large  hemorrhages. 


198  THE   STOMACH. 

The  absence  of  free  hydrochloric  acid  in  the  contents  of  the 
stomach  in  cancer  of  that  organ  is  the  rule.  It  was  at  one  time 
thought  that  this  might  help  in  the  diagnosis,  but  it  has  been 
found  that  the  free  acid  is  absent  with  a  variety  of  other  diseases 
of  the  stomach.  Pain  referred  to  the  region  of  the  stomach  is  a 
frequent  symptom,  and  the  pain  may  be  very  severe,  but  the 
number  of  patients  who  do  not  at  any  time  have  any  pain  is  very 
considerable. 

The  presence  of  a  tumor  is  the  most  certain  evidence  of  gastric 
cancer.  We  look  for  tumors  of  the  pylorus  in  the  epigastric  re- 
gion, unless  the  stomach  is  dilated,  then  the  tumors  are  found 
lower  down  in  the  abdomen.  The  tumors  of  the  greater  curva- 
ture and  of  the  anterior  wall  correspond  in  their  situation  to  these 
parts  of  the  stomach.  All  tliese  tumors  are  most  easily  felt  if  tlie 
patient  takes  a  deep  breath  so  as  to  depress  the  diaphragm.  The 
tumors  usually  move  pretty  freely  up  and  down  with  the  m.ove- 
nients  of  the  diaphragm,  but  sometimes  they  are  fastened  down 
by  adhesions.  If  they  are  close  to  the  abdominal  aorta  the 
tumors  seem  to  pulsate.  As  a  rule  there  is  no  great  difficulty  in 
making  out  that  the  tiunor  is  separate  from  the  aorta,  but  some- 
times it  is  exceedingly  difficult  to  distinguish  between  cancer  of 
the  stomach  and  aneurism  of  the  aorta. 

Cancers  of  the  cardiac  end  of  the  stomach  cannot  be  felt. 

The  ease  with  which  the  tumor  can  be  felt  depends  not  only 
on  its  position,  but  also  on  its  size  and  shape.  Some  of  the  flat 
infiltrations  of  the  w^all  of  the  stomach  never  make  an  appreci- 
able tumor.  The  flattened  and  polypoid  tumors  cannot  be  felt 
until  they  have  reached  some  size,  so  that  often  enough  we  do 
not  make  out  the  tumor  until  a  few  months  before  death.  If 
the  lymphatic  glands  are  adherent  and  infiltrated  they  increase 
the  size  of  the  tumor  very  considerably. 

It  is  not  uncommon  for  persons  to  have  a  chronic  gastritis 
with  its  attendant  symptoms  for  a  number  of  years  before  the 
canqer  is  formed.  The  symptoms  of  the  gastritis  and  those  of 
the  cancer  then  seem  to  make  one  continuous  history. 

In  the  later  stages  of  the  disease  there  may  be  a  moderate 
rise  of  temperature. 

The  bowels  are  usually  constipated,  but  tliere  may  be  diar- 
rhoea. When  there  is  bleeding  from  the  stomach  some  of  the 
blood  may  come  away  with  the  stools. 

The  loss  of  flesh  and  of  strength  are  sometimes  the  first  symp- 


THE   STOMACH.  1 99 

toms  to  attract  attention,  but  more  frequently  they  come  after 
the  gastric  symptoms  have  ah-eady  existed  for  some  time.  A 
very  considerable  loss  of  flesh  accompanying  gastric  symptoms 
always  makes  one  think  of  cancer  of  the  stomach.  But  it  must 
not  be  forgotten  that  there  are  exceptional  cases  in  which  there 
is  no  emaciation  and  the  general  health  continues  to  be  remark- 
ably good. 

There  is  regularly  some  diminution  in  the  quantity  of  haemo- 
globin and  the  number  of  red  blood-cells,  the  color  of  the  skin 
changing  to  white  or  yellow.  In  some  cases,  however,  these 
changes  in  the  blood  are  as  marked  as  they  are  in  pernicious 
anaemia,  and  when  no  tumor  is  present  the  diagnosis  becomes 
very  difficult. 

Late  in  the  disease  there  may  be  oedema  of  the  legs,  ascites, 
and  thrombosis  of  some  of  the  veins,  especially  those  of  the  legs. 

A  coma  with  dyspnoea,  like  that  of  diabetes,  has  been  observed 
in  a  few  cases  of  gastric  cancer. 

The  ordinary  duration  of  the  disease  is  about  one  year,  but 
some  cases  go  on  much  longer — for  two,  or  even  three  years. 

COURSE    OF    THE    DISEASE. 

1.  A  considerable  number  of  cases  give  a  characteristic  his- 
tory—  first  the  gastric  symptoms,  then  the  loss  of  flesh  and 
strength  with  a  tumor  in  the  upper  part  of  the  abdomen  evidently 
connected  with  the  stomach.  * 

2.  Not  infrequently  we  see  patients  with  well-marked  gastric 
symptoms  and  some  loss  of  flesh  and  strength,  but  there  is  no 
tumor,  and  the  diagnosis  may  remain  doubtful  for  some  time. 

3.  There  are  patients  in  whom  the  gradual  loss  of  nutrition 
and  cachectic  condition  are  such  as  to  make  one  feel  sure  there 
is  a  cancer  somewhere  in  the  body,  but  there  are  no  local  symp- 
toms and  no  tumor  to  tell  where  it  is. 

4.  There  are  patients  who  up  to  the  time  of  death  have  the 
symptoms  and  the  condition  of  the  blood  which  belong  to  per- 
nicious anaemia,  with  ver\'  little  to  call  attention  to  the  condition 
of  the  stomach. 

5.  There  are  cases  with  a  primary  cancer  of  the  stomach, 
which  is  of  small  size  and  gives  but  few  symptoms,  and  large 
secondary  tumors  in  the  liver.  These  patients  behave  as  if  they 
had  cancer  of  the  liver  rather  than  cancer  of  the  stomach. 


200  THE   SMALL   INTESTINE. 

6,  A  primary  cancer  of  the  stomach  may  be  followed  by  the 
formation  of  secondary  tumors  in  the  peritoneum,  with  fluid  in 
the  peritoneal  cavity.  In  some  of  these  cases  the  symptoms  of 
the  cancer  of  the  peritoneum  are  much  more  marked  than  those 
of  the  gastric  cancer. 

Treaimefit.—The  patients  can  often  be  made  much  more  com- 
fortable, and  even  enabled  to  eat  ordinary  meals,  by  the  daily 
washing  out  of  the  stomach.  Another  plan  is  to  feed  them  every 
two  hours  with  small  quantities  of  easily  digestible  food.  If  the 
pain  is  bad,  morphine  has  to  be  used. 

A  number  of  operative  procedures  have  been  employed  by 
which,  in  some  cases,  life  has  been  prolonged.     , 

Acute  Catarrhal   Enteritis, 

The  small  intestine  is  sometimes  the  seat  of  a  catarrhal  in- 
flammation which  may  be  of  mild  or  of  severe  type. 

Such  an  inflammation  is  especially  common  in  young  adults, 
some  of  whom  seem  to  have  a  predisposition  for  the  disease.  In 
some  cases  there  is  a  history  of  indigestible  food,  or  of  exposure 
to  the  weather  ;  in  other  cases  no  exciting  cause  can  be  discov- 
ered. 

Symptoms. — The  patients  have  marked  and  constant  pain  and 
tenderness  referred  to  the  lower  part  of  the  abdomen.  There  is 
a  rapid  rise  of  temperature  from  ioo°  to  104°  F,  There  is 
marked  prostration  from  the  first,  the  patients  being  at  once  con- 
fined to  bed.  There  may  be  vomiting,  the  bowels  are  consti- 
pated. The  invasion  of  the  disease  is  sudden,  the  patients  often 
seem  seriously  ill,  but  yet  they  regularly  recover.  The  fever 
subsides  first,  then  the  pain,  and  in  one  or  two  weeks  the  pa- 
tients are  well.  Sometimes,  however,  the  pain  pei"sists  for  a 
longer  time  after  the  subsidence  of  the  other  symptoms. 

Diagnosis. — The  disease  may  be  mistaken  for  inflammation  of 
the  vermiform  appendix,  for  peritonitis,  or  for  gastritis. 

Treatment. — The  patients  are  to  be  kept  in  bed  ;  at  first  on  a 
fluid  diet  ;  when  the  fever  has  subsided,  on  meat  principally. 
Continuous  heat  or  cold  should  be  applied  over  the  abdomen. 
At  first,  morphine  and  calomel  together  are  given  in  small  doses, 
later  belladonna  and  ipecac.  The  bowels  are  to  be  moved  every 
day  by  enemata. 


THE   SMALL   INTESTINE.  20I 


Cholera  Morbus. 


This  name  is  given  to  an  acute  catarrhal  inflannnation  of  the 
gastro-intestinal  tract,  probably  associated  with  tlie  growth  of 
pathogenic  bacteria. 

Lesions. — After  death  t!ie  mucous  membrane  of  tlie  stomach 
and  intestines  is  found  coated  with  mucus,  congested,  sometimes 
with  little  abscesses  in  the  glandular  coat. 

Causes. — The  disease  is  especially  common  in  the  hot  weather 
of  August  and  September.  As  exciting  causes  improper  food 
and  contaminated  water  are  probable. 

Symptoms. — The  attacks  are  apt  to  come  on  in  the  night. 
There  is  first  a  feeling  of  abdominal  oppression  and  of  prostra- 
tion. Then  the  patients  empty  the  stomach  of  food  and  the  in- 
testines of  faeces.  After  this  there  is  frequent  vomiting  and 
purging  of  white  or  brownish  fluid.  There  may  be  colicky  ab- 
dominal pains,  and  painful  contractions  of  the  muscles  of  the 
abdomen  and  of  the  legs.  The  patients  are  anxious,  restless, 
much  prostrated,  tormented  by  thirst,  the  skin  cold,  the  body 
soon  emaciated,  the  heart's  action  rapid  and  feeble.  The  pa- 
tients often  seem  seriously  ill,  but  yet  as  a  rule  recover.  Occa- 
sionally, however,  the  disease  proves  fatal,  especially  in  old  or 
feeble  persons. 

In  some  cases  cholera  morbus  cannot  be  distinguished  from 
true  cholera  except  by  the  absence  of  the  cholera  bacillus.  The 
vomiting,  purging,  rapid  emaciation,  collapse,  and  death  give  the 
same  clinical  picture  in  both  diseases. 

Treatment. — The  patients  are  to  be  kept  in  bed,  hot  fomenta- 
tions are  to  be  applied  over  the  abdomen,  and  opium  and  stimu- 
lants are  to  be  given  according  to  the  indications  of  each  case. 
The  food  should  be  in  small  quantities— koumyss,  beef-juice, 
milk,  or  cream  and  water. 

Cholera  Infantum. 

This  name  is  given  to  a  disease  of  young  children  which  re- 
sembles cholera  morbus,  and  is  probably  due  to  the  growth  in 
the  intestines  of  pathogenic  bacteria. 

Lesions. — After  death  the  intestines  contain  white  or  brown- 


202  THE   SMALL   INTESTINE. 

ish  fluid.  The  mucous  membrane  is  pale,  tlie  solitary  and  ag- 
minated  glands  are  sometimes  swollen,  sometimes  ulcerated. 

Causes. — The  disease  belongs  to  children  under  two  years  of 
age.  It  is  most  apt  to  attack  those  who,  from  bad  food,  bad  air, 
or  heat,  have  their  intestinal  tract  already  in  an  unhealthy  con- 
dition. 

Symptoms. — The  disease  may  follow  an  ordinary  diarrhoea,  or 
begin  suddenly  with  purging,  vomiting,  and  prostration.  Vom- 
iting is  usually,  but  not  always,  present,  and  varies  as  to  its 
fi"equency  and  persistency.  Purging  is  constant  and  frequent. 
The  movements  are  at  first  fecal,  afterward  of  white  or  brownish 
fluid.  The  patients  rapidly  lose  flesh  and  strength,  the  heart's 
action  is  rapid  and  feeble,  there  is  constant  thirst,  the  skin  is 
cold,  the  urine  is  diminished.  The  patients  are  always  restless 
and  miserable,  some  of  them  have  muscular  tvvitchings,  general 
convulsions,  alternating  delirium  and  stupor. 

The  disease  may  not  last  more  than  twenty-four  hours,  or  it 
may  continue  for  several  weeks.  It  is  always  serious,  and  often 
fatal. 

Treatment. — The  children  are  to  be  fed  with  small  quantities 
of  koumyss,  cream  and  water,  wine-whey,  beef-juice,  or  milk  and 
barley-water.  In  the  prolonged  cases  oil  may  be  rubbed  into  the 
skin.  The  children  should  be  kept  as  cool  as  possible,  and  sent 
to  a  different  climate  from  that  in  which  they  have  been  taken 
sick.  Of  drugs  the  most  reliable  seem  to  be  combinations  of 
mercury,  alkalies,  and  opium  in  small  doses.  Stimulants  maybe 
necessary. 

Constipation. 

In  the  healthy  adult  there  should  be  a  movement  from  the 
bowels  once  in  each  twenty-four  hours.  The  faeces  should  be 
formed,  of  natural  consistence  and  color.  In  some  individuals 
the  regular  interval  is  shorter,  in  some  it  is  rather  longer,  the 
character  of  the  faeces  remaining  normal.  If  the  bowels  cease  to 
move  regularly,  .and  the  fecal  matters  accumulate  in  the  colon, 
the  patient  becomes  liable  to  a  variety  of  disorders. 

In  the  treatment  of  constipation  it  is  important  to  determine 
its  cause  and  then  to  manage  it,  principally  by  attention  to  the 
diet  and  mode  of  life. 

In  some  persons  constipation  is  merely  due  to  the  habit  of 
only  going  to  the  water-closet  when  they  feel  the  impulse  to  def- 


THE   SMALL   INTESTINE.  203 

ecate,  whether  it  is  once  a  day  or  once  a  weetc.  In  many  of  tliese 
patients  the  temporary  use  of  a  simple  laxative  or  of  a  glycerine 
enema,  with  the  enforcement  of  a  regular  daily  hour  for  the  defe- 
cation, is  all  that  is  necessary. 

In  some  patients  tiie  constipation  is  due  to  chronic  gastritis. 
If  the  gastritis  is  improved  by  treatment,  the  constipation  will 
disappear. 

Tlie  constipation  may  be  due  to  an  insufficient  production  of 
bile.  Then  we  must  at  first  use  the  drugs  which  increase  the 
formation  of  bile — ipecac,  podophyllin,  bichloride  of  mercury, 
sulphate  of  magnesia,  the  alkalies,  or  the  mineral  acids.  Later 
the  patient  must  take  sufficient  exercise  and  gradually  give  up 
the  use  of  the  drugs. 

The  constipation  may  be  due  to  general  bad  health  or  anaemia, 
and  the  treatment  has  to  be  directed  principally  to  the  relief  of 
these  conditions. 

Improper  food  and  drink  may  be  the  cause  of  the  constipa- 
tion. The  patients  require  fruits,  vegetables,  and  starches  in 
considerable  quantities.  Thev  must  take  sufficient  water,  or  one 
of  the  alkaline  waters,  coffee,  or  beer. 

The  most  difficult  cases  to  manage  are  those  in  which  the 
sensibility  of  the  mucous  coat  of  the  colon  is  diminished  and  its 
muscular  coat  relaxed.  In  these  patients  we  apply  massage  and 
electricity  to  the  abdomen,  enforce  proper  exercise  and  diet,  and 
give  strychnia,  aloes,  and  belladonna. 

In  elderly  persons  the  rectum  may  become  filled  with  re- 
tained faeces  to  such  an  extent  as  to  give  a  good  deal  of  trouble. 

In  the  milder  cases  the  condition  is  not  constant,  but  occurs 
from  time  to  time.  The  patient  fails  to  have  an  operation  of  the 
bowels  for  several  days.  He  feels  dull,  languid,  loses  his  ap- 
petite, has  headache,  is  troublea  with  flatulence  and  uncomfort- 
able feelings  in  the  abdomen,  which  may  even  amount  to  colic. 
After  a  few  days  there  is  a  slight  diarrhoea.  The  passages  are 
small,  painful,  do  not  give  a  feeling  of  relief.  The  patient  is,  at 
the  same  time,  very  much  prostrated,  vomits  his  food,  and  may 
even  take  to  his  bed.  If  you  are  called  to  attend  these  patients 
after  the  diarrhoea  has  begun,  it  is  very  important  that  you  siiould 
recognize  the  true  nature  of  the  case.  The  administration  of  any 
preparation  of  opium,  or  of  any  drug  which  merely  checks  the 
diarrhoea,  only  does  harm  and  prolongs  the  sufferings  of  the 
patient      A  mild  laxative,  on  the  other   hand,  will  very  promptly 


204  THE   LARGE   INTESTINE. 

relieve  all  the  symptoms.  The  ordinary  dinner-pill  is  one  of  the 
best  preparations  for  this  purpose.  Eneniata  of  castor-oil  and 
olive-oil  mixed  together  are  serviceable. 

In  the  more  severe  cases  the  symptoms  come  on  gradually. 
The  patient  is  at  first  only  a  little  constipated  ;  the  bowels  move 
every  few  days,  either  of  themselves  or  with  an  enema,  or  with 
some  laxative.  And  yet  during  this  time  the  large  intestine  is 
not  really  emptied,  but  there  is  a  constant  accumulation  of  faeces 
in  the  rectum.  The  constipation  becomes  gradually  more  pro- 
nounced, and  the  patient  finds  that  enemata  and  mild  laxatives 
no  longer  give  him  a  movement.  Then  he  may  use  more  active 
purgatives,  which  produce  a  number  of  fluid  stools  and  yet  do 
not  empty  the  large  intestine  of  the  hardened  faeces,  which  are 
still  accumulating.  So  the  patient  goes  on  from  bad  to  worse, 
alternating  between  constipation  and  diarrhoea,  always  uncom- 
fortable, often  with  very  severe  pain  in  the  abdomen,  losing 
strength  rapidly.  If  the  condition  is  not  relieved,  an  old  per- 
son may  be  so  reduced  in  this  way  as  to  die  without  any  other 
disease  than  constipation. 

The  first  point  in  the  treatment  is  to  introduce  your  finger 
into  the  rectum  and  ascertain  whether  or  not  it  is  filled  with 
hardened  faeces.  If  it  is,  the  faeces  must  be  scooped  out  with 
the  finger  or  some  convenient  instrument,  and  then  the  rectum 
should  be  washed  out  repeatedly  until  it  is  entirely  emptied. 

After  this  the  patient  must  be  constantly  watched  and  exam- 
ined from  time  to  time,  to  ascertain  that  the  faeces  are  not  accu- 
mulating again.  The  diet  must  be  regulated,  and  aloes  and 
strychnine  may  be  employed  to  assist  the  action  of  the  large  in- 
testine. 

In  young  and  middle-aged  adults  constipation  may  be  pro- 
longed for  many  days,  and  the  fecal  matters  accumulate  in  the 
ascending  and  transverse  portions  of  the  colon.  When  this  is 
the  case  the  patients  often  become  quite  seriously  ill.  They  are 
in  bed  with  severe  abdominal  pain,  an  anxious  face,  some  dis- 
tention of  the  abdomen,  and  a  considerable  rise  of  temperature. 
Many  of  them  look  as  if  they  had  general  peritonitis.  In  some 
of  them  the  fecal  tumor  can  be  felt.  The  cases  vary  as  to  the 
relative  prominence  of  the  fever,  or  the  fecal  tumor,  as  symptoms. 

As  a  rule,  by  the  use  of  calomel,  castor-oil,  and  enemata,  the 
colon  can  be  emptied  and  the  patient  recover. 


THE   LARGE   INTESTINE.  20  = 


DiARRHCEA, 


A  person  is  said  to  have  diarrlioea  if  lie  has  every  day  several 
loose  fecal  or  watery  evacuations  from  the  bowels. 

Causes. — Apart  from  the  diarrhoeas  which  are  d'.ie  to  inflamma- 
tions or  new-growths  of  the  colon,  we  find  the  condition  pro- 
duced by  a  variety  of  causes. 

Mental  emotions  often  produce  a  transitory  diarrhoea,  which 
requires  no  treatment. 

Extremes  of  heat  and  cold  may  cause  a  diarrhoea  for  which  it 
is  necessary  to  put  the  patient  to  bed,  with  a  restricted  diet  and 
the  use  of  a  little  opium. 

Partly  decaved  fruit  and  vegetables,  or  undigested  pieces  of 
food  in  the  intestine,  often  set  up  a  diarrhoea.  When  this  is  the 
case  it  is  necessary  first  to  give  a  purgative  to  remove  the  irrita- 
tive substances,  and  afterward  to  use  opium. 

Drinking-water  which  contains  an  excess  of  inorganic  or  or- 
ganic substances  is  a  frequent  source  of  diarrhoea  ;  some  persons 
being  especially  susceptible  to  this  source  of  irritation. 

There  is  a  form  of  diarrhoea  in  adults  which  is  often  very 
troublesome.  In  some  of  the  patients  the  colon  seems  to  be  un- 
naturally irritable,  so  that  improper  food  or  atmospheric  changes 
frequently  bring  on  attacks  of  diarrhoea,  abdominal  pain,  pros- 
tration, and  mental  depression,  which  last  for  a  few  days  and 
then  disappear. 

In  other  cases  the  same  symptoms  — diarrhoea,  abdominal  pain, 
prostration,  and  mental  depression — are  present  during  so  much 
of  the  time  that  it  seems  probable  that  the  patients  have  a  sub- 
acute catarrhal  colitis.  In  these  protracted  cases  the  diarrlioea  is 
usually  in  the  morning,  or  immediately  after  each  meal.  These 
symptoms  often  continue  for  years,  and  come  back  repeatedly 
after  ceasing  for  a  time.  In  the  severe  cases  there  is  a  decided 
loss  of  flesh  and  strength. 

An  exclusive  diet  of  milk,  or  of  scraped  beef  ;  change  of  cli- 
mate ;  cold-water  enemata  ;  castor-oil,  arsenic,  iron,  quinine,  sali- 
cylic acid,  salol,  and  naphthaline  are  among  our  most  efficient 
methods  of  treatment. 


206  THE   LARGE   INTESTINE. 


Infantile    Diarrhcea. 

Diarrhoea  is  a  common  disorder  of  infants  and  of  young  chil- 
dren. It  is  especially  common  during-  the  period  of  dentition,  in 
hot  weather,  and  in  bottle-fed  children. 

The  diarrhcea  may  follow  an  acute  gastritis,  an  acute  coli- 
tis, or  begin  of  itself.  The  children  have  every  day  a  number 
of  loose,  bad-smelling,  green,  or  light-colored  fecal  passages. 
There  may  be  a  febrile  movement,  especially  in  the  afternoon. 
The  patients  gradually  lose  flesh  and  strength.  Such  a  diar- 
rhoea may  last  for  days,  weelis,  or  months. 

Treatment. — If  the  children  have  a  good  nurse  they  continue 
to  nurse.  If  not,  they  are  fed  on  cream  and  water,  milk  diluted 
with  a  thin  gruel,  or  koumyss.  Older  children  can  take  beef- 
juice  and  scraped  meat. 

The  medicines  usiially  employed  are  :  calomel,  bichloride  of 
mercury,  sulphate  of  magnesia,  castor-oil,  podophyllin,  rhubarb, 
ipecac,  bismuth,  and  opium. 

Occasionally  we  see  cases  in  which  there  is  first  an  ordinary 
diarrhoea.  Then  the  passages  become  white,  larger  and  larger, 
until  the  child  passes  three  or  four  times  a  day  enormous  quan- 
tities of  white,  pasty  faeces.  The  children  are  tormented  by 
hunger  and  thirst,  and  become  very  much  emaciated.  They 
should  be  removed  to  as  different  a  climate  as  possible  from  the 
one  vi'here  they  were  taken  sick.  The  most  efficient  medicine 
seems  to  be  a  combination  of  hydrochloric  acid,  arsenic,  and 
opium. 

Intestinal    Colic. 

This  name  is  given  to  attacks  of  pain  due  to  spasmodic  con- 
traction of  the  muscular  coat  of  the  colon. 

Such  attacks  may  be  due  to  the  presence  in  the  intestine  of 
irritating  pieces  of  food,  or  fecal  matter.  In  some  persons  the 
colon  seems  to  be  much  more  irritable  than  it  is  in  others,  so 
that  attacks  of  colic  are  easily  produced. 

Symptoms. — The  attacks  are  apt  to  come  on  suddenly  with 
pain  as  the  first  symptom,  and,  in  the  mild  cases,  the  only 
symptom.  The  pain  is  referred  to  some  part  of  the  colon,  or  to 
any  part  of  the  abdomen.  Besides  the  pain,  there  may  be  re- 
traction,   tenderness  on  pressure,  distention  or  hardness  of  the 


THE    LARGE    INTESTINE.  20/ 

abdominal  wall,  nausea  and  vomiting,  a  skin  ccjld  and  bathed  in 
perspiration  ;  rapid  and  feeble  heart  action,  and  a  rise  of  tem- 
perature. 

The  attacks  vary  greatly  as  to  their  severity  and  duration. 
The  mild  attacks  last  half  an  hour,  or  a  few  hours,  the  yjain  is  the 
only  symptom,  and  it  is  evident  that  the  patients  are  not  se- 
riously ill.  The  severe  attacks  last  for  days,  with  nausea  and 
vomiting,  a  good  deal  of  tenderness  as  well  as  pain  over  the 
colon,  prostration,  and  sometimes  a  febrile  movement,  so  that 
the  patient  may  look  very  badly.  The  same  patient  may  have 
one  attack  of  colic,  or  several.  It  may  be  very  difficult  to  dis- 
tinguish intestinal  colic  from  biliary  colic  without  jaundice. 

Ti'eatment. — The  object  of  treatment  is  to  relax  the  muscular 
spasm  and  to  remove  irritating  substances  from  the  intestine. 
To  relax  the  muscular  spasm  we  use  hypodermic  injections  of 
morphine  and  belladonna,  hot  fomentations  over  the  abdomen, 
and  hot-water  enemata.  To  remove  the  irritating  substances  we 
give  castor-oil  or  some  other  piurgative. 

In  some  persons  the  predisposition  to  attacks  of  intestinal 
colic  exists  in  an  unusual  degree.  These  persons  will  go  on 
year  after  year  with  repeated  attacks,  at  first  at  intervals  of 
months,  then  at  shorter  intervals,  until  finally  the  attacks  may 
occur  every  day.  These  patients  also  usually  suffer  from  flatu- 
lence and  constipation.  When  it  takes  this  protracted  form  in- 
testinal colic  becomes  a  serious  matter.  The  patients  lose  flesh 
and  strength,  they  are  unable  to  work,  the  severe  pain  gets  them 
into  the  habit  of  using  opium. 

Of  these  protracted  cases  some  are  easily  relieved  by  treat- 
ment, others  are  very  troublesome.  It  may  be  necessary  to  put 
them  for  a  time  on  an  exclusive  diet  of  scraped  beef,  or  it  mav 
be  sufficient  to  exclude  milk,  tea,  coffee,  beer,  soup,  and  most  of 
the  fruits  and  vegetables.  The  bowels  must  be  kept  open  and 
sufficient  exercise  insisted  on  as  soon  as  the  patient  can  bear  it. 
Opium  must  only  be  used  at  the  time  of  an  acute  attack,  it  must 
not  be  continued  for  any  length  of  time.  The  drugs  which  seem 
to  be  of  the  most  service  are  :  belladonna,  ipecac,  nux  vomica, 
cannabis  indica,  and  sodium  sulphocarbolate. 


208  THE   LARGE   INTESTINE. 


Acute  Colitis. 


The  glandular  coat,  the  connective-tissue  coat,  the  muscular 
coat,  the  peritoneal  coat,  and  the  lymphatic  glands  of  the  intes- 
tine are  often  the  seat  of  acute  and  of  chronic  inflammation.  It 
has  been  customary  to  include  all  these  inflammations  under  the 
name  of  dysentery,  or  to  group  them  under  the  names  of  catar- 
rhal, croupous,  and  follicular  colitis. 

I  think  that  our  knowledge  of  the  different  forms  of  colitis 
is  sufficient  to  warrant  us  in  using  more  exact  terms. 

Etiology. — Sporadic  cases  of  colitis  occur  in  all  climates.  In 
New  York  they  are  especially  common  in  August,  September, 
and  October.  Contaminated  water  and  food  and  atmospheric 
conditions  seem  to  act  as  exciting  causes.  Whenever  large 
numbers  of  people  are  brought  together  with  irregular  supplies 
of  food,  contaminated  water,  and  imperfect  sanitary  arrangements 
colitis  is  likely  to  prevail.  In  every  war  there  is  always  a  large 
mortality  from   colitis. 

Local  epidemics  of  colitis  are  of  frequent  occurrence.  Some- 
times they  can  be  accounted  for  by  contaminated  water,  at 
other  times  it  is  difficult  to  account  for  their  origin. 

There  can  be  no  question  that  colitis  is  especially  prevalent 
and  frequent  in  tropical  countries  and  in  malarial  districts. 

The  bacteriology  of  colitis  is  still  incomplete.  There  can  be 
little  doubt  that  the  amoeba  coli  causes  many  of  the  cases  of 
necrotic  colitis.  It  is  probable  that  the  streptococci  are  respon- 
sible for  some  cases,  farther  than  this  we  have  no  exact  knowl- 
edge. 

Classification. — A  convenient  classification  of  the  different 
forms  of  colitis  is  as  follows  : 

1.  Acute  exudative  colitis. 

2.  Acute  purulent  colitis. 

3.  Acute  productive  colitis. 

4.  Necrotic  colitis,  a.  Colitis  with  superficial  necrosis  (strep- 
tococci), b.  Colitis  with  necrosis,  croupous  form.  c.  Colitis  with 
deep  necrosis  (amoebae),  d.  Colitis  with  deep  necrosis  (without 
amoebae). 


THE   LARGE   INTESTINE.  209 


I.    ACUTE    EXUDATIVE    COLITIS. 


Synonyms. — Acute  catarrhal  colitis,  dysentery. 

Definition. — An  acute  exudative  inflammation  involving  the 
glandular  and  connective-tissue  coats  of  the  colon,  attended  with 
congestion,  exudation,  and  an  increased  production  of  mucus. 

Lesions. — As  this  form  of  colitis  is  rarely  fatal  in  adults  our 
knowledge  of  the  lesions  is  derived  from  it  as  it  occurs  in  chil- 
dren, as  it  is  associated  with  other  forms  of  colitis,  as  it  is  pro- 
duced experimentally  in  animals,  and  from  the  character  of  the 
discharges  from  the  bowels  during  life.  In  the  more  acute  cases 
of  this  form  of  colitis  the  inflammation  is  usually  confined  to  tlie 
lower  end  of  the  colon.  The  glandular  and  connective-tissue 
coats  are  swollen  and  congested  and  more  or  less  infiltrated  with 
serum  and  pus-cells.  There  is  an  increased  production  of  mucus, 
which  coats  the  inner  surface  of  the  colon  and  comes  away  with 
the  stools.  There  may  be  bleeding  from  the  surface  of  the  in- 
flamed mucous  membrane. 

In  the  more  subacute  cases  the  inflammation  involves  a  con- 
siderable part  of  the  length  of  the  colon,  there  is  less  congestion, 
but  the  quantity  of  serum  exuded  may  be  large. 

Symptoms. — In  the  more  acute  cases,  when  the  lower  portion 
of  the  colon  alone  is  inflamed,  the  inflammation  regularly  runs 
its  course  within  a  week  and  the  patients  recover.  The  princi- 
pal symptoms  are  the  local  ones:  pain  in  the  rectum,  an  irrita- 
bility of  its  mucous  membrane,  which  makes  it  try  to  discharge 
everything  in  contact  with  it,  and  the  passage  of  small  quanti- 
ties of  blood  and  mucus.  Although  the  passages  of  blood  and 
mucus  are  frequent,  but  little  fecal  matter  comes  away  with 
them.  Besides  the  local  S3miptoms  there  is  a  moderate  rise  of 
temperature,  v;ith  more  or  less  prostration. 

If,  however,  the  inflammation  not  only  involves  the  rectum 
but  extends  up  into  the  colon  the  patients  are  more  seriously  ill, 
especially  if  they  are  young  children.  The  quantity  of  mucus 
discharged  from  the  bowels  is  considerable  and  no  fecal  matter 
may  appear  in  the  stools  for  one  or  two  weeks.  As  the  inflam- 
mation subsides  the  quantity  of  mucus  decreases  and  the  quan- 
tity of  fecal  matter  increases.  Minute  examination  of  the  stools 
(Councilman)  shows  red  blood-cells,  white  blood-cells,  epithe- 
lial  Cells,  and    bacteria.     In    these   patients   the  temperature  is 


2IO  THE   LARGE   INTESTINE. 

higher,  the  duration  of  the  disease  longer,  and  the  prostration 
greater.     Adults  regularly  recover,  but  children  often  die. 

In  the  more  subacute  cases  the  inflammation  may  only  last 
for  a  few  days,  but  not  infrequently  it  continues  for  several 
weeks.  There  is  no  pain  in  the  rectum,  no  irritability  of  its  mu- 
cous membrane,  no  small  passages  of  blood  and  mucus.  But 
during  each  twenty-four  hours  there  are  a  number  of  large  pas- 
sages composed  of  fluid  faeces,  serum,  and  mucus.  A  single  one 
of  these  discharges  may  measure  more  than  two  quarts.  There 
may  also  be  colicky  pains.  The  patients,  as  a  rule,  are  not  con- 
fined to  bed,  although  they  feel  weak  and  miserable.  Tliere  is 
no  febrile  movement. 

Treatment. — In  the  acute  form  of  the  disease  the  patients  are 
to  be  kept  in  bed.  The  diet  is  restricted  to  milk,  gruel,  beef- 
juice,  and  scraped  beef.  The  colon  is  to  be  emptied  of  faeces,  by 
the  use  of  castor-oil  or  the  sulphate  of  magnesia.  The  pain  is 
to  be  relieved  by  opium. 

For  the  subacute  cases,  the  treatment  is  to  be  varied  with  the 
individual.  Most  of  the  patients  need  opium  at  first.  In  addi- 
tion to  tins  we  find  that  ipecac,  naphthaline,  salol,  beta-naphthol, 
bismuth,  subnitrate  of  bismuth,  and  castor-oil  in  small  doses  are 
of  service,  either  given  separately  or  in  different  combinations. 

2.    ACUTE    PURULENT    COLITIS. 

Synonyms. — Acute  catarrhal  colitis,  dysentery. 

Definition. — An  acute  exudative  inflammation  of  the  colon 
with  congestion,  exudation,  a  large  emigration  of  white  blood- 
cells,  and  an  increased  production  of  mucus. 

Lesions. — The  changes  are  the  same  as  in  exudative  colitis, 
with  the  exception  of  the  large  emigration  of  white  blood-cells 
These  are  found  in  large  numbers  infiltrating  the  connective-tis- 
sue coat,  and  the  tissue  between  the  tubules  of  the  glandular 
coat. 

Sy?nptoms. — The  clinical  picture  is  that  of  an  acute  exudative 
colitis  of  severe  type.  In  some  cases  the  whole  appearance  of 
the  patients  is  that  of  septic  poisoning  with  diarrhoea.  The  in- 
flammation is  frequently  fatal,  but  it  is  impossible  to  determine 
what  the  proportion  is  between  deaths  and  recoveries. 


THE   LARGE   INTESTINE.  211 


3.    ACUTE    PRODUCTIVE    COLITIS. 

Synonyms. — Catarrhal  colitis,  dysentery. 

I}efiuition. — An  acute  inflammation  of  the  colon  attended  with 
exudation  from  the  vessels,  an  increased  production  of  mucus, 
and  a  growth  of  new  tissue  between  the  glandular  tubules  and 
in  tlie  connective-tissue  coat. 

Lesions. — The  inflammation,  as  a  rule,  involves  a  considerable 
part  of  the  length  of  the  colon.  The  gross  appearance  is  that  of 
congestion  and  moderate  thickening,  sometimes  a  number  of 
small,  superficial  ulcers  can  be  seen.  The  principal  changes  are 
in  the  glandular  coat.  We  find  there  a  growth  of  fibro-cellular 
tissue  between  the  glandular  tubules,  with  disappearance  of  the 
tubules.  There  is  also  a  growth  of  cells  in  the  connective-tissue 
coat.  The  little  ulcers  are  formed  by  necrosis  of  small  portions 
of  the  glandular  coat. 

Symptoms. — In  children,  who  are  only  sick  for  a  few  days  and 
then  die  from  the  colitis,  the  symptoms  are  those  of  acute  exu- 
dative colitis.  But  after  death  we  find  that  the  growth  of  new 
tissue  between  the  glandular  tubules  has  already  begun. 

More  frequently  the  inflammation  continues  for  a  longer 
time.  The  patients  are  ill  for  weeks  or  for  months,  or  go  on  to 
have  chronic  colitis.  In  these  long-continued  cases  we  usually 
find  small  superficial  ulcers  of  the  glandular  coat  if  the  disease 
is  fatal. 

The  patients  begin  with  more  or  less  abdominal  pain,  and  a 
number  of  loose  fecal  passages.  Besides  the  fecal  matter,  there 
may  also  be  discharges  of  mucus  and  blood.  Tenesmus  may  be 
present  or  absent. 

The  temperature  varies  very  mucli.  In  some  cases  it  will 
hardly  be  above  the  normal  at  any  time,  in  other  cases  there  will 
be  a  temperature  of  between  100°  and  103°  F.  throughout  the 
disease.      The  afternoon  temperatures  are  the  highest. 

The  patients  are  not  at  first  very  sick,  but  gradually  lose  flesh 
and  strength,  until  they  are  glad  to  go  to  bed  and  stay  there. 

Vomiting  is  often  present  at  the  beginning  of  the  disease,  and 
there  may  be  so  much  nausea  as  to  make  feeding  very  difficult. 

As  long  as  the  colitis  continues  the  patients  have  numerous 
fluid  fecal  passages,  and  from  time  to  time  they  pass  blood  and 
mucus. 


212  THE   LARGE   INTESTINE. 

A  considerable  number  of  the  patients  recover,  but  a  duration 
of  three  or  four  weeks  is  not  uncommon  even  in  the  favorable 
cases. 

Treatjnent.- — The  patients  are  to  be  put  to  bed  and  on  a  fluid 
diet,  but  in  the  protracted  cases  they  must  not  be  deprived  of 
solid  food  for  too  long  a  time. 

The  drug  which  answers  the  best  purpose  is  castor-oil  in  doses 
of  from  five  to  twenty  drops,  three  or  four  times  a  day.  At  first 
opium  has  to  be  given  with  the  castor-oil,  later  it  is  given  by 
itself  or  with  salol. 


4.    NECROTIC    COLITIS. 

(<?.)  Productive  Colitis  with  Superficial  Necrosis. 

This  is  the  same  as  the  form  of  productive  colitis  just  de- 
scribed, the  cases  varying  as  to  the  extent  of  the  necrosis. 

((^.)  Croupous  Colitis. 

Lesions. — The  mucous  membrane  is  congested,  swollen,  infil- 
trated with  fibrine  and  pus,  and  a  layer  of  fibrine  and  pus  is 
formed  on  its  free  surface.  There  is  superficial  or  deep  necrosis 
of  the  inflamed  portions  of  the  colon.  The  inflammation  is 
sometimes  diffuse,  more  frequently  confined  to  a  number  of 
small,  circumscribed  portions  of  the  mucous  membrane.  The 
inflammation  may  involve  the  rectum  alone,  or  the  rectum  with 
more  or  less  of  the  colon.  After  the  inflammation  has  subsided 
superficial  or  deep  ulcers  are  left,  according  to  the  extent  of  the 
necrosis. 

This  form  of  colitis  is  always  severe,  and  often  fatal.  It  be- 
haves as  do  the  infectious  inflammations. 

Symptoms. — The  patients  have  numerous  small,  painful  pas- 
sages of  blood  and  mucus.  If  the  inflammation  extends  above 
the  rectum  they  also  pass  large  quantities  of  brownish  fluid. 
There  is  nearly  constant  pain,  irritability,  and  a  desire  to  go  to 
stool.  There  may  also  be  colicky  pains,  strangury,  vomit- 
ing, and  jaundice.  There  is  regularly  a  febrile  movement, 
sometimes  preceded  by  chills,  throughout  the  disease  ;  but  in 
some  of  the  bad  cases  the  temperature  is  low  throughout.  In 
the  severe  cases  the  prostration  is  marked,  the  heart's  action  is 


THE   LARGE   INTESTINE.  213 

rapid  and  feeble,  delirium,  stupor,  or  convulsions  are  developed. 
The  disease  lasts  for  from  one  to  six  weeks. 

Pi'ognosis. — Croupous  colitis  is  a  very  serious  disease.  It  is 
often  fatal  ;  it  is  often  followed  by  chronic  colitis.  It  is  especially 
fatal  in  old  persons,  in  young  children,  in  tropical  countries,  with 
epidemics,  with  inflammation  of  the  entire  length  of  the  colon. 

Treatment. — The  patients  are  to  be  kept  in  bed  and  on  a  fluid 
diet  ;  they  may  require  stimulants.  Of  medicines,  the  most  effi- 
cient are  castor-oil,  sulphate  of  magnesia,  ipecac,  salol,  and 
opium.  The  castor-oil  and  sulphate  of  magnesia  are  given  at  long 
intervals  and  in  full  doses,  to  empty  the  colon  of  faeces.  They 
are  given  in  small  doses,  at  short  intervals,  to  lessen  the  colitis. 
The  ipecac  is  given  once  or  twice  a  day,  in  doses  of  from  ten  to 
twenty  grains.  The  salol  is  given  in  five-grain  doses  at  intervals 
of  from  one  to  four  hours.     The  opium  is  given  to  relieve  pain. 

(<r.)  Amebic  Colitis. 

This  is  a  severe  form  of  necrotic  colitis  apparently  due  to  the 
presence  in  the  wall  of  the  colon  of  the  amoeba  coli.  It  seems 
to  be  especially  common  in  tropical  countries,  but  is  not  rare  in 
temperate  climates.  Tlie  method  of  infection  has  not  been  de- 
termined. 

Lesions. — A  considerable  part  of  the  whole  length  of  the  colon 
is  usually  involved. 

The  amoeba  coli  is  a  single  spheroidal  cell,  from  five  to  eight 
times  the  diameter  of  a  red  blood-cell,  with  granular  protoplasm 
and  a  vesicular  nucleus.  It  often  contains  vacuoles.  When 
seen  alive  on  the  warm  stage  it  will  change  its  shape  and  posi- 
tion. It  is  found  in  the  stools,  in  the  connective-tissue  coat  of 
the  colon,  in  abscesses  in  the  liver,  and  in  abscesses  in  the  lungs. 
A  great  number  of  micrococci  and  of  bacilli  of  different  kinds 
are  also  found  in  the  stools  and  in  the  intestinal  ulcers. 

The  morbid  process  seems  to  begin  in  the  form  of  circum- 
scribed thickening,  infiltration,  and  necrosis  of  portions  of  the 
connective-tissue  coat  of  the  colon.  These  changes  are  appar- 
ently due  to  the  presence  of  the  amoeba  coli.  The  necrosis  soon 
extends  to  the  glandular  coat,  and  ulcers  are  formed  which  ex- 
tend down  to  the  muscular  or  peritoneal  coats  and  have  over- 
hanging edges.  In  addition  there  are  more  or  less  infiltration  of 
the  walls  and   floors   of   the    ulcers   with  pus-cells,  cell  growth 


214  THE   LARGE   INTESTINE. 

between  the  glandulai^  tubules,  and  increased  production  of 
mucus  in  the  tubules  which  are  left.  These  additional  changes 
seem  to  be  due  to  the  mixed  infection  by  the  other  bacteria 
which  are  present  in  the  intestine.  The  cases  vary  as  to  the  size 
and  number  of  the  ulcers.  In  the  bad  cases  nearly  the  whole  of 
the  glandular  coat  of  the  colon  is  destroyed. 

In  a  considerable  number  of  cases  of  amoebic  colitis  there  are 
abscesses  in  the  liver.  There  may  be  one  or  two  large  abscesses, 
or  a  great  many  small  ones.  There  is  first  necrosis  of  portions 
of  the  liver,  tlien  softening  and  breaking  down,  and  then  more  or 
less  suppuration  of  the  walls  of  the  cavities. 

Similar  necrotic  abscesses  containing  amoebi  may  be  found 
in  the  right  lung. 

Symptoms. — The  invasion  of  the  symptoms  is  either  acute  or 
gradual. 

In  the  acute  cases  the  patient  is  suddenly  attacked  with 
colicky  pains  and  diarrhoea,  often  with  nausea  and  vomiting, 
and  sometimes  a  rise  of  temperature.  The  stools  are  frequent, 
fluid,  and  sooner  or  later  contain  blood  and  mucus.  The  quan- 
tity of  blood  may  be  considerable. 

In  the  more  gradual  invasion  there  is  at  first  nothing  but  a 
painless  diarrhoea — several  loose,  fecal  stools  in  the  twenty-four 
hours. 

The  patients  have  no  appetite,  the}^  lose  flesh  and  strength, 
and  become  anaemic.  In  some  of  them  the  symptoms  are  con- 
tinuous, in  others  there  are  remissions  and  exacerbations.  Al- 
though the  temperature  may  reach  104°  F.,  the  febrile  movement 
is  not  a  feature  of  the  disease.  The  most  noticeable  symptoms 
are  the  frequent  stools  of  fluid  faeces,  bad-smelling  fluid,  mucus, 
and  blood,  the  pains  in  the  abdomen,  and  the  progressive  loss  of 
flesh  and  strength.  The  disease  may  only  continue  for  two 
weeks,  or  it  may  be  protracted  over  several  months.  The  same 
patient  may  have  several  attacks  of  the  disease. 

A  serious  complication  is  the  formation  of  the  amoebic  ab- 
scesses of  the  liver,  which  may  occur  at  any  time  in  the  coiarse 
of  the  colitis,  either  in  mild  or  sev^ere  cases. 

Of  less  frequent  occurrence  are  the  amcebic  abscesses  in  the 
lungs,  with  cough  and  bloody,  foul-smelling  expectoration. 

I  have  seen  one  case  in  which  the  pulmonary  symptoms  pre- 
ceded the  diarrhoea  by  three  days. 

Perforation  of  the  intestine  followed  by  collapse  or  by  peri- 


THE   LARGE    INTESTINE.  215 

tonitis  sometimes  occurs.  There  may  also  be  peritonitis  without 
perforation. 

The  pi-ognosis  is  serious,  not  only  from  the  extent  of  the  de- 
struction of  the  wall  of  the  colon,  but  from  the  liability  to  abscess 
of  the  liver,  abscess  of  the  lung,  and  peritonitis. 

Treatment. — While  the  disease  is  active  the  patients  are  kept 
in  bed  and  on  a  fluid  diet ;  they  may  require  alcoholic  stimulants. 

For  the  pain  and  sleeplessness,  small  doses  of  some  prepara- 
tion of  opium  are  necessary. 

For  the  colitis  ipecac  in  large  doses,  or  castor-oil  in  small 
doses,  seems  to  be  the  most  useful  drugs. 

Large  enemata  of  solutions  of  bichloiide  of  mercury  i  to  5,000, 
and  of  quinine  i  to  5,000,  have  been  employed. 

d.    Colitis  with  Necrosis  and  Siippiiration  without  Amxbce. 

I  have  seen  several  fatal  cases  of  which  the  symptoms  were 
the  same  as  those  of  amoebic  colitis,  but  there  were  no  abscesses 
of  the  liver  or  lung,  no  amoebae  in  the  stools  or  in  the  wall  of  the 
intestine,  but  very  extensive  necrosis  and  suppuration  of  the  con- 
nective-tissue coat  of  the  colon. 

I  have  also  seen  patients  who  recovered  from  an  illness  last- 
ing for  several  weeks  and  resembling  amoebic  colitis,  but  without 
anv  amoebae  in  the  stools. 


CHRONIC    CATARRHAL    COLITIS. 

This  regularly  follows  an  acute  or  subacute  productive  colitis. 

Lesions. — The  rectum  alone  is  the  portion  of  the  colon  which 
is  most  frequently  involved  in  chronic  inflammation,  but  the  rest 
of  the  colon  is  also  liable  to  the  same  changes.  There  is  regularly 
an  increased  quantity  of  mucus  produced  by  the  mucous  glands  ; 
thickening  of  the  glandular  coat  alone,  or  of  all  the  coats  of  the 
colon  ;  sometimes  ulceration  of  the  glandular  coat,  sometimes 
little  polypoid  growths  on  the  surface  of  the  mucous  membrane. 
It  is  surprising  to  find  how  little  anatomical  change  in  the  mu- 
cous membrane  is  associated  wnth  a  fatal  diarrhoea. 

Symptoms. — The  cases  vary  as  to  the  severity  of  the  inflamma- 
tion, the  extent  of  colon  inflamed,  and  as  to  whether  the  colitis 
is  chronic  from  the  outset,  or  succeeds  an  acute  colitis. 

In  the  mild  cases  the  general  health  may  remain  fairly  good, 


2l6  THE   LARGE   INTESTINE. 

although  the  patients  pass  every  day  more  or  less  mucus,  and 
occasionally  a  little  blood.  In  the  severe  cases,  besides  the  mu- 
cus and  blood  there  are  numerous  discharges  of  fluid  faeces,  the 
patients  lose  flesh  and  strength,  and  finally  may  die  exhausted  by 
the  disease. 

Treatment. — The  patients  do  best  in  a  dry  inland  climate.  The 
food  must  be  restricted,  even  an  exclusive  milk  diet  may  be  neces- 
sary. The  best  medicines  are  castor-oil  in  small  doses,  the  min- 
eral acids,  ipecac,  naphthalin,  and  salol. 

Membranous  Enteritis. 

This  is  a  chronic  catarrhal  colitis  attended  with  a  large  pro- 
duction of  verv  tenacious  mucus,  which  comes  away  with  the 
stools  in  the  form  of  masses,  cords,  or  tubes  looking  like  mem- 
branes. 

Causes. — The  disease  belongs  to  middle  life,  and  is  more  com- 
mon in  women  than  in  men. 

Symptoms. — So  far  as  the  colon  is  concerned,  the  symptoms 
are  :  constipation,  sometimes  diarrhoea,  flatulence  with  its  attend- 
ant pains,  and  the  passage  at  varying  intervals  of  the  so-called 
membranes  already  mentioned. 

But  with  these  symptoms  are  usually  associated  complicating 
conditions  which  are  often  more  distressing  than  the  intestinal 
symptoms.  There  may  be  gastric  dyspepsia,  functional  disorders 
of  the  liver,  diseases  of  the  uterus  and  ovaries,  hysteria,  or  hypo- 
chondriasis. 

Prognosis. — The  disease  is  not  often  a  fatal  one,  but  yet  a  con- 
siderable time  may  elapse  before  the  patient  entirely  recovers. 

Treatment. — In  the  more  severe  cases  the  patients  must  be  put 
on  milk  diet,  or  the  use  of  scraped  beef  and  hot  water.  An  out- 
of-door  life  in  a  dry  inland  climate  is  regularly  of  service. 

The  most  useful  drugs  are  the  alkalies,  the  mineral  acids, 
small  doses  of  castor-oil,  ipecac,  and  sometimes  small  doses  of 
opium.  There  is  also  sometimes  an  advantage  in  the  use  of 
large  enemata  of  cold  water,  and  of  massage  of  the  abdomen. 

Chronic  Colitis  with  Ulcers. 

Lesions. — The  ulcers  are  small  or  large,  numerous  or  few,  close 
together  or  scattered,  confined  to  the  rectum  or  extending  up  on 
the  colon.     The  mucous  membrane  between  the  ulcers  is  more 


THE    LARGE    INTESTINE.  21/ 

or  less  clianged  by  catarrhal  inflammation.  The  walls  of  the 
floors  of  the  ulcers  are  formed  of  granulation  tissue. 

Causes. — The  ulcers  are  regularly  formed  during  the  course 
of  an  acute  necrotic  colitis. 

Symptoms. — The  patients  have  frequent  passages  of  blood,  of 
mucus,  or  of  fecal  matter.     They  steadily  lose  flesh  and  strength. 

Treatment. — The  patients  are  to  be  managed  in  the  same  way 
as  those  who  suffer  from  catarrhal  colitis.  But  if  the  ulcers  are 
situated  low  down  in  the  rectum,  there  is  also  an  advantage  in 
the  use  of  local  applications  to  the  ulcers.  These  applications 
may  be  made  by  suppositories,  or  by  enemata,  or  the  patient  is 
etherized  and  the  ulcers  brought  into  view  with  the  speculum. 

Carcinoma  of  the  Colon. 

The  new-growth  usually  follows  the  type  of  colloid  cancer,  or 
of  glandular  cancer  with  cylindrical  cells.  The  favorite  situa- 
tions are  the  rectum  and  the  caput  coli.  The  new-growth  sur- 
rounds the  gut  and  extends  longitudinally  for  one  or  two  inches  ; 
less  frequently  it  involves  a  considerable  part  of  the  length  of 
the  colon.  The  growth  may  cause  a  stricture  of  the  colon,  or 
may  project  inward  in  soft  masses,  or  may  ulcerate.  It  often 
infiltrates  the  surrounding  tissues,  it  may  cause  a  local  peritoni- 
tis, or  the  ulceration  may  go  on  to  perforate  the  wall  of  the 
colon. 

Causes. — The  disease  occurs  regularly  in  persons  over  thirty 
years  of  age. 

Symptoms. — If  the  growth  is  situated  in  the  rectum  the  first 
symptoms  are  constipation,  flatulence,  pain,  and  constricted 
stools  ;  or  simply  a  number  of  small  fecal  passages  every  day. 
The  patients  complain  of  the  annoyance  of  having  to  defecate  so 
frequently  instead  of  having  a  single  large  movement.  In  other 
patients  there  is  at  first  a  diarrhoea,  the  passages  are  fluid,  and 
more  or  less  blood  and  mucus  are  also  passed.  At  first,  and 
even  for  a  number  of  months,  the  general  health  suffers  very 
little. 

As  the  disease  continues  the  local  symptoms  become  more 
marked,  and  the  patients  lose  flesh  and  strength  and  become 
cachectic.  The  tumor  can  be  felt  in  the  rectum  as  a  hard  ring 
constricting  the  gut,  or  as  a  hard  diffuse  mass  about  the  gut,  or 
as  a  soft  tumor  projecting  inward.     As  the  disease  goes  on  the 


2l8  THE   LARGE   INTESTINE. 

stricture  becomes  tighter  and  tighter  ;  or  there  is  paralysis  of 
the  sphincter  witli  a  constant  flow  of  brown,  sanious  fluid. 

The  patients  die  worn  out  with  the  disease,  or  with  retention 
of  faeces,  or  from  perforation  of  the  intestine,  or  from  peritonitis. 

If  the  growth  is  situated  in  the  caput  coli  the  first  symptoms 
are  gradual  loss  of  flesh  and  strength,  flatulence,  alternating 
diarrhoea  and  constipation,  nausea,  and  vomiting.  Or  the  first 
symptom  is  pain  coming  on  in  attacks,  first  at  long  intervals,  then 
more  and  more  frequently.  These  symptoms  continue,  the  pa- 
tients lose  flesh  and  strength,  and  become  cachectic  ;  there  may 
be  distention  of  the  small  intestine.  The  tumor  can  be  felt  in 
the  right  side  of  the  abdomen,  when  it  has  reached  a  sufficient 
size. 

Occasionally  we  see  cases  of  cancer  of  the  rectum,  or  of  the 
caput  coli,  in  which  there  are  no  local  symptoms.  The  only  evi- 
dences of  the  disease  are  the  loss  of  flesh  and  strength,  and  the 
tumor. 

Treatment. — The  only  efficient  treatment  is  the  removal  of 
the  tumor  by  a  surgical  operation. 


THE  LIVER. 


The  liver  occupies  the  riglit  liypocliondriac  region,  and  ex- 
tends toward  tlie  left  into  and  a  little  beyond  the  epigastrium. 
Its  upper  surface  is  in  contact  with  the  diaphragm,  its  lower  sur- 
face touches  the  stomach  and  the  colon.  The  upper  border  of 
the  liver  is  at  the  level  of  the  fourth  or  fifth  rib  in  the  mammary 
line,  at  the  level  of  the  seventh  rib  in  the  axillary  line,  at  the 
level  of  the  eighth  or  tenth  rib  behind.  The  upper  border  is 
overlapped  by  the  lungs  down  to  the  sixth  rib  in  front,  and  to 
the  tenth  rib  behind.  Tlie  lower  border  comes  down  to  the  free 
edge  of  the  ribs  in  front.  The  fundus  of  the  gall-bladder 
touches  the  anterior  abdominal  wall  immediately  beneath  the 
free  border  of  the  ribs  opposite  the  tip  of  the  tenth  costal 
cartilage. 

To  determine  the  size  of  the  liver,  the  patient  is  placed  on  his 
back.  Percussion  is  made  from  above  downward  in  the  mam- 
mary line,  and  should  give  dulness  at  the  fourth  or  fifth  rib, 
flatness  at  the  sixth  rib,  and  from  thence  down  to  the  free  border 
of  the  ribs.  Percussion  in  the  axillary  line  should  give  flatness 
at  the  seventh  rib.  The  lower  border  of  the  liver  is  made  out  by 
percussion  and  palpation,  the  latter  is  the  more  certain.  In 
practising  palpation  the  patient  should  breathe  deeply  so  as  to 
depress  the  diaphragm  and  liver.  It  is  easy  to  mistalve  the  right 
rectus  muscle  for  the  right  lobe  of  the  liver.  Another  tnethod  of 
palpation  is  to  make  the  patient  sit  bending  forward  and  resting 
his  arms  on  a  chair.  The  physician  sits  beliind  tlie  patient  and 
examines  through  the  relaxed  abdominal  wall. 

As  regards  the  component  parts  of  the  liver  :  the  liepatic 
cells  are  liable  to  a  variety  of  degenerative  changes  ;  the  con- 
nective-tissue stroma  may  be  the  seat  of  exudative,  suppurative, 
productive,  or  necrotic  inflammation  ;  the  blood-vessels  may  be 
occluded,  obliterated,  or  inflamed  ;  the  bile-ducts  maybe  obliter- 
ated, or  inflamed,  or  may  contain  calculi. 


220  THE   LIVER. 

Of  the  functions  of  the  liver  the  two  which  principally  con- 
cern us  are  :  the  production  of  bile,  and  the  chemical  changes 
effected  in  the  blood  coming  from  the  portal  vein. 

1.  The  Production  of  Bile. — This  fluid  is  produced  at  the  rate 
of  about  forty  ounces  in  each  twenty-four  hours.  It  passes  into 
tlie  duodenum,  thence  into  the  intestinal  tract,  where  part  re- 
mains, and  part  is  reabsorbed  by  the  lymphatics  of  the  wall  of 
the  intestine.  The  portions  which  remain  in  the  intestine  assist 
in  the  digestion  of  fat  and  peptones,  act  as  an  antiseptic  to  pre- 
vent the  decomposition  of  the  contents  of  the  intestine,  assist  in 
exciting  the  peristaltic  action  of  the  colon,  and  are  finally  dis- 
charged mixed  with  the  fseces. 

2.  The  Chemical  Changes  Effected  in  the  Blood. — The  blood  from 
the  abdominal  viscera,  charged  with  the  matters  absorbed  from 
the  intestine,  passes  through  the  entire  venous  system  of  the 
liver.  While  it  does  this  the  matters  contained  in  it  undergo 
chemical  changes  and  are  separated  into  excrementitious  sub- 
stances which  are  eliminated  by  the  kidneys,  and  other  sub- 
stances which  circulate  in  the  blood  and  nourish  the  tissues. 

Functional  Disorders  of  the  Liver. 

The  functions  of  tlie  liver  may  be  disordered  either  with  or 
without  structural  disease  of  this  organ.  These  disorders  may 
occur  by  themselves,  or  be  associated  with  disturbances  of  the 
stomach  and  of  the  intestines. 

The  cases  may  be  arranged  in  two  groups  : 

I.  disturbances  of  the  bile-producing  functions  of  the  liver. 

The  quantity  of  bile  produced  is  too  small.  This  is  followed 
by  imperfect  digestion  of  fats  and  peptones  and  consequent  loss 
of  nutrition  ;  by  decomposition  of  the  matters  contained  in  the 
intestine,  with  flatulence  and  possible  poisoning  ;  and  by  consti- 
pation. 

The  patients  become  anaemic  and  emaciated,  or  are  rather 
fat,  but  yet  feeble  and  flabby.  They  are  constipated,  with  flatu- 
lence and  its  associated  pains.  The  faeces  are  hard  and  light 
colored.  The  tongue  is  coated,  the  mouth  and  throat  are  dry, 
with  a  bitter  taste.  The  skin  is  pale  and  muddy.  The  appetite 
is  poor  and  capricious.     The  urine  contains  an  excess  of  oxalate 


THE   LIVER.  221 

or  phosphate  of  lime.  Tliere  are  headache,  mental  lassitude,  and 
abnormal  sensations  in  different  parts  of  the  body.  In  the  bad 
cases  hypochondriasis,  neurasthenia,  hysteria,  or  melancholia 
may  be  developed. 

Treatment. — The  object  of  treatment  is  to  increase  the  produc- 
tion of  bile,  and  this  is  to  be  effected  by  improving  the  general 
health,  and  by  using  remedies  which  will  increase  the  produc- 
tion of  bile. 

In  the  milder  cases  the  patients  should  eat  meats,  vegetables, 
and  fruits,  take  exercise  in  the  open  air,  and  one  hour  before 
meals  take  a  tumbler  of  hot  water  with  a  small  quantity  of 
sulphate  of  magnesia.  Or,  instead  of  this,  aloes,  podophyllin, 
rhubarb,  ipecac,  phosphate  of  soda,  sulphocarbolate  of  soda, 
bichloride  of  mercury,  or  the  mineral  acids,  may  be  given  sepa- 
rately or  in  various  combinations. 

In  the  more  severe  cases  the  patients  may  be  so  feeble  that 
they  require  rest  in  bed  and  massage  for  a  time  before  they  can 
begin  to  take  exercise. 

Some  of  the  patients  are  benefited  by  cold-water  douching 
and  by  the  use  of  iron. 

2.    IMPERFECT  CHEMICAL    CHANGES    IN    THE    BLOOD    WHICH    PASSES 
THROUGH    THE    LIVER. 

These  patients  seem  to  be  able  to  digest  all  kinds  of  food,  for 
their  nutrition  does  not  suffer,  and  they  are  often  large,  strong, 
florid  persons.  Not  infrequently  they  habitually  eat  and  drink 
too  much.     They  may  have  the  gouty  diathesis. 

The  most  marked  symptoms  are  :  Feelings  of  fulness  in  the 
head,  vertigo,  loss  of  memory,  abnormal  sensations  in  different 
parts  of  the  body,  hypochondriasis,  sometimes  morning  diarrhoea. 
The  urine  is  scanty  and  high  colored,  it  contains  an  excess  of 
uric  acid  and  of  urates.  It  may  contain  small  quantities  of 
albumin  and  of  sugar. 

Treatment. — The  patients  should  avoid  the  use  of  tobacco, 
wines,  spirits,  sugars,  and  starches.  They  should  take  active  ex- 
ercise. They  often  get  temporary  relief  by  the  use  of  purga- 
tives. They  may  be  much  benefited  by  the  regular  course  of 
treatment  at  Carlsbad. 


222  THE    LIVER. 


Jaundice. 


This  name  is  used  to  designate  the  staining  of  the  skin  and 
many  of  the  tissues  and  fluids  of  the  body  by  tlie  coloring  matter 
of  the  bile. 

The  pigment  is  found  in  the  urine  ;  it  stains  the  conjunctiva, 
skin,  mucous  membranes,  the  sweat,  and  the  discharges  from 
wounds. 

It  has  been  customary  to  distinguish  two  forms  of  jaundice  : 

I.  Obstructive,  or  hepatogenous,  jaundice,  caused  by  an  ob- 
struction of  the  hepatic  or  common  bile-duct.  The  bile  accumu- 
lates in  the  bile-ducts  within  the  liver,  is  reabsorbed  from  the 
biliary  passages  and  circulates  in  tlie  blood.  2.  Non-obstruc- 
tive, or  iiaematogenous  jaundice.  In  this  form  of  jaundice  it  was 
supposed  that  the  bile  is  formed,  passes  into  the  intestine,  is  re- 
absorbed into  the  blood  ;  but  after  being  reabsorbed  into  the 
blood  the  regular  chemical  changes  which  dispose  of  tl:e  color- 
ing matter  of  the  bile  do  not  take  place.  So  this  coloring  mat- 
ter circulates  unchanged  in  the  blood  throughout  the  body. 

At  the  present  time  the  disposition  is  to  hold  that  all  jaun- 
dice is  caused  by  obstruction,  but  that  the  obstruction  may  in- 
volve the  large  bile-ducts  without  the  liver,  or  the  small  ducts 
within  the  liver. 

1.  Obstruction  of  the  bile-ducts  outside  of  the  liver  (the  he- 
patic and  common  ducts)  is  usually  caused  by: 

Biliary  calculi,  inspissated  bile,  or  foreign  bodies  from  the 
duodenum. 

Inflammation  of  the  common  bile-duct  or  of  the  duodenum. 

Congenital  malformations  of  the  bile-ducts,  perihepatitis, 
ulcers  of  the  duodenum. 

Tumors  of  the  bile-duct,  or  of  the  duodenum. 

Pressure  on  the  bile-ducts  by  tumors  in  the  abdominal  cavity. 

2.  Obstruction  of  the  bile-ducts  within  the  liver  is  seen  with  : 
Cirrhosis  of  the  liver,  fatty  liver,  and  tumors  of  tlie  liver. 
The  infectious  diseases,  especially  their  more  malignant  forms. 
The  severity  of  the  symptoms  of  jaundice  are  in  proportion 

to  the  quantity  of  bile-pigment  which  accumulates  in  the  blood 
and  tissues,  and  the  length  of  time  during  which  the  jaundice 
continues. 

The  mild  and  temporary  forms  of  jaundice  give  no  symptoms. 


THE   LIVER.  223 

The  well-marked  forms,  lasting  for  a  number  of  days,  are  ac- 
companied by  :  A  deep  yellow  color  of  the  skin  and  mucous 
membranes,  constipation,  the  faeces  white  or  clay  colored,  the 
urine  of  a  dark  yellow  color,  the  mind  rather  dull  and  apathetic, 
sometimes  headache,  sometimes  a  rise  of  temperature,  the  pulse 
full  and  slow,  loss  of  appetite,  sometimes  nausea  and  vomiting, 
more  or  less  loss  of  strength,  itching  of  the  skin. 

The  severe  cases,  in  which  the  jaundice  increases  and  cannot 
be  relieved,  pass  into  the  condition  of  alternating  stupor  and  de- 
lirium, lose  flesh  and  strength  rapidly,  bleed  into  the  skin  and 
from  the  mucous  membranes  and  finally  die. 


SIMPLE,    OR    CATARRHAL,    JAUNDICE. 

Lesions. — There  is  a  catarrhal  inflammation  of  the  common 
bile-duct  alone,  or  in  addition  there  is  a  catarrhal  gastritis,  or  a 
catarrhal  duodenitis.  The  inflammation  is  attended  with  so 
much  swelling  of  the  mucous  membrane  of  the  common  bile-duct 
as  to  obstruct  the  flow  of  bile  from  the  liver  into  the  intestine. 

Symptoms. — The  patients  suffer  from  general  malaise,  head- 
ache, dulness,  sleepiness,  or  vertigo.  The  tongue  is  coated,  there 
is  loss  of  appetite,  nausea,  and  vomiting.  There  may  be  a  febrile 
movement.  Sometimes  there  is  pain  over  the  duodenum.  After 
one  or  more  days  comes  the  yellow  color  of  the  conjunctiva 
and  of  the  skin,  the  clay-colored  faeces,  and  the  dark-colored 
urine,  with  the  itching  of  the  skin.  The  urine,  besides  the  bile 
pigment,  contains  albumin  and  casts.  After  the  appearance  of 
the  jaundice  the  gastric  symptoms  may  subside. 

If  the  bile-duct  alone  is  inflamed  the  cases  run  a  mild  course. 
The  one  symptom  is  the  jaundice.  The  patients  are  not  confined 
to  bed,  the  cerebral  symptoms  are  slight,  there  is  no  vomiting 
and  no  fever. 

If  the  duodenum  is  inflamed  as  well  as  the  common  bile-duct 
the  prostration  is  more  marked.  There  is  often  a  good  deal  of 
pain  in  the  epigastrium.  Nausea,  vomiting,  and  a  febrile  move- 
ment are  absent,  or  not  severe. 

If  the  stomach  also  is  inflamed  the  condition  of  the  patients  is 
much  worse.  They  are  often  confined  to  bed.  There  may  be 
stupor  and  delirium.  Nausea,  vomiting,  and  a  febrile  movement 
are  regularly  present.  The  symptoms  of  the  gastritis  may  pre- 
cede by  several  days  the  appearance  of  the  jaundice. 


224  THE   LIVER. 

When  gastro-duodenitis  with  jaundice  occurs  in  a  person  who 
already  has  a  cirrhotic  or  a  fatty  liver,  it  is  often  fatal. 

Treatment. — While  the  symptoms  are  active  the  patient  is  kept 
in  bed  and  on  a  fluid  diet,  with  the  addition  of  sodium  bicarbo- 
nate to  the  milk.  As  the  gastric  symptoms  subside  they  get  back 
to  solid  food,  even  when  they  are  jaundiced.  The  jaundice  is 
treated  by  enemata.  Either  a  quart  of  ice-water  is  slowly  intro- 
duced into  the  rectum  and  then  passed  ;  or  a  quart  of  hot  water 
is  used  in  the  same  way.  These  injections  are  given  once  or 
twice  a  day. 

Instead  of  this  an  enema  of  half  a  pint  of  olive-oil  and  half  an 
ounce  of  castor-oil  is  given  every  day  and  retained  for  as  long  a 
time  as  possible. 

CHRONIC     JAUNDICE. 

Although  cases  of  simple  jaundice  usually  run  their  course 
within  a  few  weeks  and  recovei^,  yet  they  sometimes  continue  for 
a  longer  time.  In  these  protracted  cases  the  disease  behaves  in 
one  of  three  ways  : 

1.  All  the  symptoms  continue  with  a  steadily  increasing  jaun- 
dice. The  patients  lose  flesh  and  strength,  there  are  bleedings 
from  the  mucous  membranes  and  in  the  skin.  The  patients  die 
after  several  months,  emaciated  and  deeply  jaundiced. 

2.  The  patients  suffer  from  repeated  attacks  of  gastro-duo- 
denitis and  jaundice.  Between  the  attacks  they  seem  almost 
well,  but  yet  there  is  always  a  little  bile  in  the  urine.  It  is  diffi- 
cult to  distinguish  these  cases  from  the  cases  with  a  movable 
calculus  in  the  common  bile-duct. 

3.  The  jaundice  continues,  but  does  not  increase.  The  pa- 
tient's general  health  remains  comparatively  good.  After  a 
number  of  montlis  the  jaundice  finally  disappears. 

Acute  Degeneration  of  the  Liver. 

Synonyms. — Acute  yellow  atrophy  of  the  liver.  Malignant 
jaundice.  As  the  result  of  some  unknown  poison  there  is  a  very 
rapid  and  fatal  degeneration  of  the  hepatic  cells  and  the  renal 
epithelium. 

Lesions. — The  liver  may  be  at  first  somewhat  enlarged  and  then 
become  smaller,  or  it  becomes  smaller  from  the  first.  The  dimi- 
nution  in   size  is   very  rapid   and  goes   on   until   the  liver  only 


THE   LIVER.  ^  225 

weighs  one  or  two  pounds.  These  very  small  livers  are  yellow 
and  flabby. 

In  other  cases  the  liver  is  not  much  diminished  in  size,  its 
consistence  is  firm,  its  color  is  mottled  red  and  yellow. 

In  all  cases  there  are  profound  changes  in  the  hepatic  cells. 
They  become  swollen,  coarsely  granular,  and  finally  disintegrate 
and  break  down. 

The  spleen  is  large  and  soft.  The  stomach  is  the  seat  of 
acute  catarrhal  inflammation. 

In  tlie  intestines  the  solitary  and  agminated  glands  are  swollen. 

The  kidneys  are  the  seat  of  very  intense  acute  degeneration. 
In  most  of  the  tubes  the  epithelial  cells  are  dead  and  detached 
from  the  walls  of  the  tubes. 

The  muscles  of  the  heart  undergo  fatty  degeneration. 

There  are  extravasations  of  blood  in  the  skin,  the  mucous 
membranes,  and  the  serous  membranes. 

Causes. — The  disease  has  been  observed  in  persons  between 
the  ages  of  one  and  sixty-nine  years,  but  it  is  especially  common 
in  persons  between  twenty  and  thirty  years  of  age.  It  is  more 
common  in  women  than  in  men.  It  has  been  seen  a  number  of 
times  in  pregnant  women. 

Syinptojns. — The  invasion  of  the  disease  is  gradual,  or  sudden. 

If  it  is  gradual,  the  patients  suffer  from  nausea,  occasional 
vomiting,  general  malaria,  sometimes  jaundice  for  from  three 
days  to  three  weeks. 

If  it  is  sudden,  the  patient  at  once  becomes  seriously  ill  with 
a  rapid  development  of  all  the  symptoms  of  the  disease. 

When  the  disease  is  established,  there  is  frequent  vomiting, 
first  of  food,  then  of  brownish  fluid,  coffee-ground  matter  and 
blood.  There  is  a  diarrhoea  with  clay-colored  faeces,  and  later 
bleeding  from  the  intestines.  Jaundice  in  two-thirds  of  the  cases 
appears  early  in  the  disease,  in  one-fourth  of  the  cases  from  the 
fifth  to  the  seventh  day,  in  a  few  cases  not  until  one  or  two  days 
before  death.  In  very  rapid  cases  there  may  be  no  jaundice. 
There  may  be  pain  over  the  region  of  the  liver.  There  is  a  fe- 
brile movement  during  the  active  period  of  the  disease,  but  the 
temperature  runs  an  irregular  course,  sometimes  very  high, 
sometimes  falling  below  the  normal.  The  pulse  becomes  rapid 
and  feeble. 

There  are  cerebral  symptoms — headache,  alternating  stupor 
and  delirium,  general  convulsions,  and  coma. 


226  )  THE   LIVER, 

The  tongue  becomes  brown  and  dry,  the  prostration  is  very 
marked. 

The  liver  may  at  first  be  enlarged  and  then  become  smaller, 
or  it  may  become  smaller  from  the  outset.  The  diminution  in 
size,  as  we  mark  it  out  by  percussion,  is  very  rapid,  and  finally 
the  liver  dulness  may  entirely  disappear.  In  some  cases,  how- 
ever, the  liver  remains  throughout  the  disease  of  nearly  normal 
size. 

The  urine  contains  bile-pigment,  albumin,  casts,  blood,  leu- 
cin,  and  tyrosin.  The  urea  and  uric  acid  are  diminished  in 
quantity. 

There  are  often  hemorrhages  from  the  stomach,  intestines, 
and  kidneys,  and  in  the  skin. 

The  ordinary  duration  of  the  active  symptoms  is  a  week,  but 
a  prolonged  period  of  invasion  may  lengthen  the  whole  time  of 
the  disease  to  four  weeks,  and  the  bad  cases  may  die  within 
twelve  hours 

The  prognosis  of  the  disease  is  very  bad. 


Cirrhosis  of  the  Liver. 

Synonym. — Chronic  interstitial  hepatitis. 

Lesions. — There  is  a  chronic  productive  inflammation  of  the 
stroma  of  the  liver  with  more  or  less  degeneration  of  the  hepatic 
cells.  Tlie  new  tissue  follows  the  distribution  of  the  stroma  of 
the  liver.  It  surrounds  large  or  small  groups  of  acini,  or  grows 
diffusely  between  the  liver-cells,  or  is  in  the  form  of  large  bands 
and  masses.  According  to  the  distribution  of  the  new  connec- 
tive tissue,  tlie  liver  is  coarsely  or  finely  nodular,  or  smooth,  or 
iobulated.  The  liver-cells  may  become  atrophied  or  fatty.  The 
small  veins  and  bile-ducts  are  often  obliterated.  The  larger  bile- 
ducts  may  be  the  seat  of  catarrhal  inflammation.  The  liver  re- 
mains of  normal  size,  or  becomes  small  or  large.  We  find  after 
death  :  small  nodular  livers,  small  smooth  livers,  large  nodular 
livers,  large  smooth  livers. 

The  obstruction  to  the  passage  of  the  blood  from  the  portal 
vein  through  the  liver  causes  the  spleen  to  become  large  and 
hard,  the  mucous  membrane  of  the  stomach  and  small  intestines 
to  be  congested  and  coated  with  mucus,  the  peritoneal  cavity 
to  contain  serum. 


THE   LIVER,  227 

Causes. — The  disease  belongs  to  adult  life,  and  is  usually 
caused  by  alcohol  or  syphilis.  It  is,  however,  occasionally  seen 
in  children,  and  may  occur  without  discoverable  cause. 

Syjnpto7?is. — These  depend  on  : 

1.  The  disturbance  of  the  bile-producing  function  of  the 
liver,  with  the  consequent  digestive  disturbances  and  loss  of 
nutrition. 

2.  The  accompanying  clironic  gastritis. 

3.  The  interference  with  the  passage  of  the  blood  through 
the  liver  and  the  consequent  dropsy. 

4.  The  development  of  jaundice. 

5.  The  existence  of  a  complicating  nephritis,  arteritis,  or 
emphysema. 

Physical  Signs. — These  depend  on  the  changes  in  tlie  size  of 
the  liver  and  the  smooth  or  nodular  character  of  its  surface  ;  on 
the  enlargement  of  the  spleen  ;  and  on  the  presence  of  f]uid  in 
the  abdominal  cavity. 

The  course  of  the  disease  varies  in  different  persons. 

1.  There  are  persons  who  have  cirrhosis  of  the  liver  for  a 
number  of  years  without  any  symptoms  to  call  attention  to  that 
organ. 

2.  In  a  good  many  cases  of  cirrhosis  the  principal  symptoms 
are  those  of  the  accompanying  chronic  gastritis.  This  gastritis 
seems  to  be  partly  due  to  chronic  alcoholism,  or  some  other  or- 
dinary cause,  partly  to  the  chronic  congestion  caused  by  the 
cirrhosis.  It  behaves  like  any  chronic  gastritis,  but  is  often 
severe  and  rebellious  to  treatment,  and  the  patient  mav  vomit 
blood  in  large  or  small  quantities. 

3.  The  anatomical  changes  in  the  liver  after  a  time  affect  the 
functions  of  the  organ  in  such  a  way  that  the  patients  steadily 
lose  flesh  and  strength.  This  loss  of  nutrition  is  a  very  constant 
symptom,  and  seems  to  have  a  large  share  in  causing  the  death 
of  the  patients.  It  is  most  frequently  associated  with  dropsy, 
but  may  exist  and  cause  death  without  any  dropsy  at  all. 

4.  Ascites  is  one  of  the  ordinary  features  of  cirrhosis;  general 
dropsy  occurs  less  frequently.  When  the  dropsy  has  once  ap- 
peared it  is  apt  to  continue,  and  the  patients  get  steadily  worse. 
But  occasionally  even  a  large  abdominal  dropsy  can  be  gotten 
rid  of  and  the  patient  do  well  for  a  number  of  years. 

5.  Patients  with  cirrhosis  of  the  liver  are  liable  to  slight  at- 
tacks of   catarrhal   jaundice,  and    to  severe    attacks    of   gastro- 


228  THE   LIVER. 

duodenitis  with  jaundice.  These  latter  attacks  are  attended 
with  fever  and  cerebral  symptoms  and  are  often  fatal, 

6.  With  the  large,  nodular,  cirrhotic  livers  (hypertrophic 
cirrhosis)  there  often  occurs  a  very  fatal  form  of  jaundice.  It 
behaves  like  a  bad  obstructive  jaundice,  although  the  hepatic 
and  common  bile-ducts  are  pervious. 

The  patients  have  pain  over  the  liver,  vomiting,  constipation, 
a  constantly  increasing  jaundice,  a  febrile  movement,  gradual 
emaciation,  and  cerebral  symptoms.     All  of  them  die. 

The  prognosis  of  cirrhosis  is  unfavorable,  but  yet  in  many 
cases  the  course  of  the  disease  is  slow,  and  in  some  it  is  arrested 
altogether.  The  patients  have  no  symptoms,  although  the  cir- 
rhosis still  exists. 

Treatment. — In  many  cases  of  cirrhosis  we  only  treat  the 
chronic  gastritis.  This  is  done  in  the  usual  way  by  regulation 
of  the  diet  and  mode  of  life  and  by  lavage.  But  it  is  found  that 
if  the  cirrhosis  progresses  it  becomes  more  and  more  difficult  to 
control  the  gastritis. 

In  the  cases  with  marked  loss  of  nutrition  the  use  of  alcohol 
and  of  tobacco  is  to  be  prohibited.  Tlie  patients  should  lead,  as 
far  as  possible,  an  out-door  life.  It  may  be  necessary  to  relieve 
constipation  and  to  give  drugs  which  increase  the  production  of 
bile. 

If  there  is  a  distinct  history  of  syphilis  it  may  be  necessary 
to  give  mercury  and  the  iodide  of  potash. 

Moderate  quantities  of  fluid  in  the  peritoneal  cavity  can  be 
gotten  rid  of  by  diuresis  and  by  purging,  but  when  the  abdomen 
is  distended  with  fluid  it  is  necessary  to  tap. 


Abscess  of  the  Liver. 

Suppurative  inflammation  of  the  liver  may  be  produced  by  a 
similar  inflammation  of  the  walls  of  the  bile-ducts  or  of  the  veins 
within  the  liver. 

Small  abscesses  are  formed  in  the  liver  by  the  lodgement  of 
infectious  emboli  in  the  vessels. 

Most  of  the  abscesses  in  the  liver  are  due  to  the  presence  and 
growth  of  the  amoeba  coli.  Whether  abscesses  are  produced  by 
traumatism,  or  by  the  ordinary  bacteria  of  suppuration,  is  un- 
certain. 


THE   LIVER.  229 

Lesions. — The  abscesses  usually  follow  one  of  four  anatomical 
forms. 

1.  They  resemble  ordinary  abscesses  in  any  part  of  the  body. 
There  are  one  or  more  abscess  cavities  of  considerable  size,  filled 
with  well-formed  pus,  and  their  walls  infiltrated  with  pus-cells. 
The  abscesses  may  be  situated  in  any  part  of  the  liver.  This  is 
the  least  fatal  form  of  liver  abscess. 

2.  There  are  one  or  more  cavities  in  the  liver  with  ragged, 
irregular,  necrotic  walls,  and  containing  a  thin  reddish,  or  brown- 
ish, or  yellow  fluid,  with  fragments  of  dead  liver-tissue,  but  very 
few  pus-cells. 

3.  A  considerable  area  of  liver-tissue  is  dead,  with  little 
cavities  filled  with  pus  or  puriform  fluid  scattered  through 
it. 

4.  The  entire  liver  is  studded  with  small  abscesses,  some  of 
them  too  small  to  be  seen  with  the  naked  eye. 

In  all  these  abscesses  the  amoeba  coli  may  be  found.  In  the 
smallest  abscesses  the  first  change  is  a  necrosis  of  the  liver-tis- 
sue. Whether  the  different  anatomical  characters  of  the  ab- 
scesses are  due  to  the  addition  of  bacterial  infection  to  the 
amoebic  infection  has  not  been  worked  out. 

If  the  abscesses  are  situated  near  the  surface  of  the  liver, 
there  will  be  exudative  inflammation  and  the  formation  of  ad- 
hesions. 

If  left  to  themselves  the  abscesses  usually  increase  in  size 
until  they  perforate  through  the  diaphragm  into  the  lung,  the 
pleura,  or  the  pericardium  ;  or  into  the  stomach,  the  intestines, 
the  peritoneal  cavity,  or  the  pelvis  of  the  right  kidney  ;  or 
through  the  anterior  abdominal  wall. 

Even  without  perforation  there  may  be  inflammation  of  the 
right  pleura,  or  abscesses  in  the  right  lung. 

Symptoms. — r.  As  it  is  observed  in  tropical  countries.  The 
invasion  is,  or  is  not,  preceded  by  the  symptoms  of  colitis.  It  is 
acute,  ushered  in  by  chills  and  a  febrile  movement  and  marked 
prostration. 

The  chills  mav  be  repeated  throughout  the  disease.  The 
fever  is  of  the  continuous,  remittent,  or  intermittent  type,  and  is 
accompanied  by  sweating.  There  are  pains  and  tenderness  over 
the  liver. 

Jaundice  is  not  a  constant  or  marked  symptom. 

Nausea  and  vomiting  are  often  present. 


230  THE   LIVER. 

There  may  be  localized,  or  general,  peritonitis.  There  may 
be  ascites  without  peritonitis. 

Perforation  of  the  abscess  is  followed  by  symptoms  accord- 
ing to  its  position. 

2.  As  it  is  observed  in  New  York.  The  invasion  is  gradual. 
There  is  sometimes  a  history  of  colitis  occurring  just  before  the 
symptoms  of  the  abscess,  or  preceding  these  symptoms  by  sev- 
eral weeks  or  months. 

The  patients  feel  chilly  and  feverish,  lose  their  appetites,  feel 
sick,  may  have  nausea  and  vomiting,  but  often  do  not  go  to  bed 
for  several  days.  After  they  get  to  bed  the  fever  continues,  with 
chills  and  sweating.  The  nausea  and  vomiting  continue,  they 
lose  flesh  and  strength,  there  are  pain  and  tenderness  over  the 
liver.  If  perforation,  or  death,  or  recovery  do  not  take  place 
these  symptoms  may  continue  for  weeks,  months,  or  years. 

The  physical  signs  vary  with  the  position  and  size  of  the  ab- 
scess. Large  abscesses  in  the  lower  part  of  the  right  lobe  of  the 
liver,  or  in  the  left  lobe,  cause  a  considerable  enlargement  of  the 
liver  downward  into  the  peritoneal  cavity. 

Abscesses  in  the  upper  part  of  the  right  lobe  of  the  liver  pro- 
jecting up  into  the  right  pleura  may  give  no  downward  enlarge- 
ment of  the  liver  at  all.  There  is  only  dulness  over  the  lower 
part  of  the  right  lung  behind,  and  this  dulness  is  more  marked 
if  there  is  fluid  in  the  pleural  cavity. 

Some  abscesses  in  the  right  lobe  only  give  a  fulness  of  the 
right  hypochondrium  without  enlargement  of  the  liver  either 
upward  or  downward.  With  small  abscesses  there  may  be  no 
enlargement  of  the  liver  at  all. 

Treatment. — The  success  of  treatment  depends  on  the  posi- 
tion and  character  of  the  abscess.  If  of  moderate  size  and  a  sin- 
gle cavity  containing  pus  it  can  be  cured  by  aspiration.  Larger 
abscesses  need  to  be  opened  and,  if  they  project  into  the  pleura, 
this  may  be  difficult.  Multiple  abscesses  and  diffuse  necrosis 
are  not  amenable  to  treatment. 

The   Fatty  Liver. 

Lesions. — There  is  a  deposit  of  fat  in  the  liver-cells,  with  an 
increase  in  the  size  of  the  liver.  There  are  no  changes  in  the 
stroma  or  in  the  blood-vessels.  The  larger  bile-ducts  may  be 
the  seat  of  acute,  or  of  chronic,  catarrhal  inflammation. 


THE    LIVER.  231 

"  Causes. — The  disease  occurs  at  all  ages.  It  is  more  common 
in  women  tlian  in  men.  It  seems  to  be  caused  by  alcoholism, 
over-eating,  want  of  exercise,  and  by  phthisis  and  other  wasting 
diseases. 

Symptoms. — i.   Many  fatty  livers  give  no  symptoms  at  all. 

2.  With  some  fatty  livers  there  are  marked  symptoms  of  dis- 
turbance of  the  functions  of  the  liver,  with  the  plivsical  signs  of 
a  large  liver.  The  patients  are  fat,  but  anaemic  and  feeble. 
Mental  lassitude  and  depression,  and  abnormal  sensations  in  dif- 
ferent parts  of  the  body  are  prominent  symptoms.  The  bowels 
are  constipated  and  the  functions  of  the  stomach  are  deranged. 
There  is  often  added  a  chronic  gastritis,  sometimes  with  vomit- 
ing of  blood. 

The  treatment  of  these  cases  is  by  regulation  of  the  diet  and 
mode  of  life,  and  the  use  of  drugs  which  increase  the  produc- 
tion of  bile. 

3.  The  infiltration  of  the  liver-cells  with  fat  maybe  unusually 
great,  and  the  increase  in  the  size  of  the  liver  enormous.  In 
these  patients  the  first  symptoms  are  those  of  disturbance  of  the 
bile -producing  function  of  the  liver,  and  of  chronic  gastritis. 
These  symptoms  do  not  improve,  but  get  worse.  The  patients 
become  so  feeble  and  anaemic  that  they  are  confined  to  bed. 
They  become  a  little  jaundiced.  They  finally  die  in  a  condition 
of  extreme  exhaustion. 

4.  Patients  with  fatty  livers  and  chronic  gastritis  are  particu- 
larly liable  to  attacks  of  acute  gastro-duodenitis  with  jaundice. 
These  attacks  are  severe,  with  a  good  deal  of  fever  and  delirium, 
and  often  prove  fatal. 

5.  Patients  with  large  fatty  livers  may  develop  an  increasing 
and  fatal  jaundice  without  obstruction  of  the  hepatic  or  common 
bile-duct.  The  jaundice  behaves  like  that  which  accompanies 
hypertrophic  cirrhosis. 

Thrombosis  of   the    Portal   Vein, 

Lesions. — The  main  trunk  of  the  portal  vein,  or  one  of  its 
branches,  is  partly  or  completely  filled  by  a  thrombus.  This 
thrombus  does  not  soften,  is  not  infectious,  but  is  replaced  by 
new  connective  tissue  so  that  the  vein  is  permanently  obstructed. 

Causes. — Cirrhosis  or  cancer  of  the  liver,  chronic  peritonitis, 
tumors  of  the  abdominal  cavity,  and  injuries  inflicted  over  the 


232  THE   LIVER. 

upper  part  of  the  abdomen  act  as  causes.  There  are  also  cases 
which  occur  without  discoverable  cause,  especially  in  old  persons. 

Symptoms. — First  there  may  be  the  symptoms  of  the  cirrhosis, 
the  cancer,  the  chronic  peritonitis,  the  tumors,  or  the  injuries. 

The  svmptoms  of  the  thrombosis  are  developed  rapidly. 
There  is  rapid  and  persistent  dropsy  of  the  peritoneal  cavity. 
The  spleen  is  enlarged.  There  are  vomiting  of  food  and  of 
blood,  diarrhoea,  and  bleeding  from  the  intestines.  The  urine  is 
scanty. 

In  some  of  the  patients  the  symptoms  continue  without  inter- 
ruption. They  become  very  feeble,  delirious,  and  unconscious. 
Death  takes  place  within  a  few  days.  In  these  patients  there 
may  be  no  dropsy.  In  other  cases,  where  the  drops}'  is  the  prin- 
cipal feature  without  much  bleeding  or  prostration,  the  patients 
may  live  for  a  long  time,  or  even  recover. 

Suppurative   Inflammation   of   the    Portal   Vein. 

Lesions. — The  wall  of  the  vein  is  thickened  and  infiltrated  with 
pus.  Its  cavity  is  filled  with  soft,  puriform,  infectious  thrombi. 
The  inflammation  and  thrombosis  extend  from  the  trunk  of 
the  portal  vein  to  its  branches  in  the  liver.  The  liver-tissue 
surrounding  the  inflamed  veins  also  becomes  the  seat  of  sup- 
purative inflammation.  Portions  of  the  thrombi  may  pass  into 
the  circulation  and  lodge  as  infectious  emboli  in  different  parts 
of  the  body. 

Causes. — Fish  bones  and  pieces  of  wire  have  been  found  im- 
bedded in  the  wall  of  the  vein. 

Inflammation  of  the  umbilical  vein  in  infants  may  extend  to 
the  portal  A-ein.  Abscesses  in  the  abdominal  cavity  may  be  fol- 
lowed by  thrombosis  and  inflammation  first  of  one  of  the 
branches  of  the  portal  vein  and  then  of  the  vein  itself.  Calculi  in 
the  common  bile-duct,  which  cause  inflammation  and  ulceration 
of  the  wall  of  the  duct,  may  also  cause  inflammation  of  the 
portal  vein.  There  are  cases  in  which  suppurative  portal  phle- 
bitis occurs  without  discoverable  cause. 

Syj)iJfto?fis. — The  invasion  of  the  symptoms  ma}-  be  sudden,  or 
preceded  by  a  few  days  of  moderate  fever,  loss  of  appetite,  and 
general  malaise.  Pain  and  tenderness  over  the  liver  are  con- 
stant S3'mptoms.  They  occur  early  in  the  disease  and  continue 
throu2:hout  its  course. 


THE    LIVER.  233 

The  liver  and  the  spleen  are  increased  in  size.  Jaundice  is 
often  present.  There  are  nausea,  vomiting  of  food  and  of  blood, 
diarrhoea,  and  passage  of  blood  from  the  bowels. 

Chills  mark  the  onset  of  the  disease,  and  are  repeated  througli- 
out  its  course.  The  temperature  rises  at  once  and  continues 
through  the  disease,  like  the  temperature  of  pyaemia,  sometimes 
high,  sometimes  low,  sometimes  below  the  normal. 

There  may  be  ascites,  or  local  or  general  peritonitis. 

The  patients  rapidly  lose  flesh  and  strength,  develop  cerebral 
symptoms,  and  pass  into  the  pysemic  condition.  The  symptoms 
are  evidently  local — dependent  on  the  inflammation  of  the  vein 
and  of  the  liver  ;  and  general — dependent  on  the  septic  poison- 
ing. 

The  disease  regularly  terminates  fatally  at  the  end  of  about 
fourteen  days  ;  but  it  may  last  only  a  few  days,  or  continue  five 
or  six  weeks. 

The  New-Growths  of   the  Liver. 

Both  carcinomata  and  sarcomata  are  often  developed  in  the 
liver  as  secondary  and  metastatic  tumors.  The  carcinomata  of 
the  stomach,  large  bile-ducts,  and  gall-bladder  are  accompanied 
with  secondary  growths  in  the  liver  in  a  large  proportion  of  the 
cases.  It  may  very  well  be  that  the  secondary  new-growth  of 
the  liver  attains  a  large  size  and  gives  more  marked  symptoms 
than  does  the  primary  tumor  from  which  it  originates. 

Of  the  primary  new-growths  of  the  liver  the  larger  number 
follow  the  type  of  carcinoma.  They  are  composed  of  tubules 
lined  with  cylindrical  epithelium,  or  filled  with  polygonal  cells  ; 
or  of  larger  and  more  irregular  spaces  packed  with  polygonal 
cells. 

Primary  sarcomata  of  the  liver  are  of  rare  occurrence.  They 
follow  the  type  of  the  sarcomata  which  seems  to  be  developed 
from  the  connective  tissue  around  blood-vessels— angiosarcoma. 

The  new-growth  may  take  the  form  of  multiple  nodules,  of 
single  tumors  which  may  reach  a  large  size,  or  of  a  diffuse  infil- 
tration. The  liver  itself  is  usually  increased  in  size,  smooth  or 
nodular,  according  to  the  arrangement  of  the  new-growth.  But 
some  of  the  livers  are  not  enlarged,  some  are  even  diminished  in 
size.  The  new-growth  may  compress  the  bile-ducts,  it  may  com- 
press, or  grow  into,  the  veins. 


234  THE   LIVER. 

There  may  be  secondary  tumors  in  the  peritoneum,  ascites,  or 
peritonitis. 

The  symptoms  of  the  primary  new-growth  in  the  liver  are 
variable  and  often  obscure. 

1.  The  patients  first  complain  of  derangements  of  digestion, 
of  gastric  dyspepsia,  and  of  functional  disturbances  of  the  liver. 
It  often  happens  that  these  symptoms  follow  symptoms  of  the 
same  kind  which  existed  before  the  formation  of  the  new-growth 
in  the  liver,  so  that  a  history  of  similar  symptoms  may  be  given 
which  extends  over  many  years.  This  means  that  the  patient 
first  suffered  from  chronic  gastritis  and  functional  disturbance  of 
the  liver,  and  then  a  new-growth  in  the  liver  was  formed,  and 
the  old  symptoms  were  made  worse  without  changing  their  char- 
acter. As  the  tumor  of  the  liver  increases  in  size  the  patients 
grow  worse.  They  lose  flesh  and  strength,  become  anaemic,  have 
an  irregular  fever,  become  a  little  jaundiced,  have  ascites,  oedema 
of  the  legs,  and  a  large  liver.  The  progress  of  the  disease  is  at 
first  slow  and  gradual,  toward  the  end  much  more  rapid. 

2.  The  patients  suffer  from  the  symptoms  of  chronic  gastritis 
and  functional  disturbance  of  the  liver.  They  slowly  lose  flesh 
and  strength  and  become  anaemic.  It  becomes  more  and  more 
evident  that  they  have  a  malignant  new-growth  in  some  part  of 
the  body,  but  it  is  impossible  to  locate  it  on  account  of  the  want 
of  local  symptoms  or  physical  signs. 

3.  There  are  rare  cases,  with  a  large  nodular  liver,  which  be- 
have like  cirrhosis,  rather  than  like  cancer. 

4.  There  are  cases  in  which  the  new-growth  very  soon  invades 
the  branches  of  the  portal  veins,  so  that  ascites  is  an  early  and 
prominent  symptom  before  there  lias  been  much  change  in  the 
general  health.  The  ascites  may  be  accompanied  by  chronic 
peritonitis.  The  cases  look  more  like  chronic  or  tubercular 
peritonitis,  or  cancer. of  the  peritoneum,  than  they  do  like  cancer 
of  tlie  liver. 

Cancer  of  the  Common  Bile-Duct. 

Lesions. — The  growth  begins  in  the  wall  of  the  common  bile- 
duct  near  the  duodenum  and  surrounds  and  constricts  the  duct. 
The  growth  may  remain  small,  or  may  extend  to  the  pancreas 
and  lymphatic  glands  and  form  large  tumors.  The  growth  con- 
stricts the  bile-duct,  prevents  the  escape  of  bile,  and  so  produces 
dilatation  of  the  bile-ducts  and  the  ffall- bladder. 


THE   LIVER.  235 

The  disease  belongs  to  persons  over  forty  years  of  age. 

Symptoms, — Jaundice  is  developed  suddenly  and  increases  in 
intensity  throughout  the  disease. 

Pain  comes  on  suddenly  and  is  referred  to  the  region  of  the 
common  bile-duct. 

Nausea  and  vomiting  often  mark  the  onset  of  the  symptoms 
and  may  continue. 

The  sudden  development  of  the  symptoms  in  a  disease  of  this 
character  is  a  noticeable  feature. 

The  patients  go  on  with  the  symptoms  of  a  very  bad  obstruc- 
tive jaundice.  The  pigmentation  of  the  skin  becomes  constantly 
deeper,  the  urine  is  loaded  with  bile-pigment,  the  faeces  are 
white.  The  patients  lose  fiesh  and  strength,  there  are  hgemor- 
rhages  in  the  skin  and  from  the  mucous  membranes,  cerebral 
symptoms  are  developed,  the  tongue  is  brown  and  dry,  the  gall- 
bladder may  be  dilated  so  as  to  form  a  tumor  of  some  size.  The 
patients  finally  die  deeply  jaundiced,  emaciated,  and  semi- 
comatose. 

The  duration  of  the  symptoms  is  usually  for  from  one  to 
three  months. 

Cancer  of  the  Gall-Bladder. 

Lesions. — The  growth  is  said  to  begin  in  the  wall  of  the  gall- 
bladder near  the  fundus  or  the  cystic  duct,  and  then  extends  until 
it  involves  a  considerable  part  of  the  bladder.  The  gall-bladder 
may  become  contracted  and  small,  or  it  may  contain  gall-stones, 
or  it  may  be  distended  with  fluid  so  as  to  form  a  tumor  of  some 
size.      There  may  be  secondary  nodules  in  the  liver. 

Symptoms. — The  clinical  histories  are  very  obscure.  The 
patients  lose  fiesh  and  strength  and  become  cachectic,  as  if  they 
had  a  cancer  in  some  part  of  the  body. 

If  the  gall-bladder  is  contracted  there  is  nothing  to  tell  us 
where  the  cancer  is. 

If  the  gall-bladder  is  dilated,  the  presence  of  the  tumor  as- 
sists in  making  the  diagnosis. 

If  the  liver  is  enlarged  and  contains  secondary  nodules,  the 
case  is  usually  supposed  to  be  one  of  cancer  of  the  liver. 


236  THE   LIVER. 


Biliary  Calculi. 

The  solid  portions  of  the  bile  may  become  separated  from  the 
fluid  portions  and  form  semi-solid,  or  solid,  masses  within  the 
biliary  passages. 

1.  Inspissated  bile  occurs  in  the  form  of  soft,  brown,  or 
greenish  masses,  composed  principally  of  bile-pigment,  with  a 
little  cholesterin,  the  salts  of  iron,  soda,  and  potash,  and  some- 
times thick,  tenacious  mucus.  While  in  the  biliary  passages  it 
retains  its  viscid  consistence,  but  when  dry  changes  into  a  fine 
powder. 

2.  Biliary  calculi  are  solid  bodies  composed  principally  of 
cholesterin  with  more  or  less  bile-pigment.  They  vary  as  to 
their  size,  shape,  color,  consistence,  and  number. 

Causes. — ^The  normal  reaction  of  the  bile  is  neutral  or  slightly 
alkaline,  if  it  becomes  acid  cholesterin  is  precipitated. 

There  may  be  such  a  large  production  of  cholesterin  that  it 
cannot  remain  in  solution. 

Any  conditions  which  retard  the  flow  of  bile  into  the  intestine, 
or  which  render  the  walls  of  the  bile-passages  unhealthy,  are 
liable  to  produce  calculi. 

Calculi  are  rare  in  children,  but  of  frequent  occurrence  in 
persons  over  twenty  years  of  age.  They  are  more  common  in 
women  than  in  men,  A  sedentary  mode  of  life,  constipation, 
excessive  eating  of  fats,  starches,  and  sugars,  and  chronic  ma- 
larial poisoning,  seem  to  have  some  effect  in  causing  the  forma- 
tion of  calculi. 

I.    CALCULI     WHICH     ARE     FORMED     IN     THE     GALL-BLADDER     AND     RE- 
MAIN   THERE. 

1.  When  calculi  are  formed  in  the  gall-bladder,  they  may  re- 
main there  and  give  absolutely  no  symptoms.  The  gall-bladder 
usually  becomes  contracted,  and  the  cystic  duct  is  obliterated. 

2.  Calculi  remaining  in  the  gall-bladder  may  from  time  to 
time  cause  attacks  of  pain  which  last  for  hours  or  days. 

These  attacks  of  pain  may  be  relieved  by  emetics  or  by  mor- 
phine. 

In  some  persons  the  attacks  of  pain  are  repeated  frequently, 
and  there  is  so  much  loss   of  flesh  and  strenjjth  that  the  matter 


THE   LIVER.  237 

becomes  serious.  It  is  then  necessary  to  open  the  gall-bladder, 
and  remove  the  calculi  by  a  surgical  operation. 

3.  Calculi  remaining  in  tlie  gall-bladder  may  act  as  irritating 
bodies,  and  excite  catarrhal  or  suppurative  inflammation  of  the 
wall  of  the  gall-bladder. 

A  catarrhal  inflammation  is  attended  with  dilatation  of  the 
gall-bladder  and  pain. 

A  suppurative  inflammation  is  attended  with  pain,  dilatation 
of  tiie  gall-bhidder,  fever,  sweating,  loss  of  flesh  and  strength. 
There  may  be  added  a  localized  peritonitis,  with  the  formation  of 
adhesions. 

If  the  patients'  general  condition  remains  good,  they  may  be 
kept  in  bed,  with  the  application  of  continuous  cold  over  the  gall- 
bladder. If  the  cases  are  at  all  threatening,  the  only  satisfactory 
treatment  is  to  open  the  gall-bladder  and  remove  the  calculi. 

II.      CALCULI     MAY     PASS     INTO     THE     CYSTIC     DUCT     AND     BECOME     IM- 
PACTED   THERE. 

1.  There  will  be  an  attack  of  biliary  colic,  or  there  are  several 
such  attacks.  After  the  last  attack  there  will  be  found  a  tumor 
formed  by  the  dilated  gallbladder.  This  tumor  may  cause  so 
little  inconvenience  that  no  treatment  for  it  is  necessary,  or  it 
may  give  so  much  discomfort  that  it  will  be  proper  to  empty  it 
by  the  aspirator. 

2.  Tliere  will  be  an  attack  of  biliary  colic  and,  after  this,  first 
dilatation  and  then  inflammation  of  the  gall-bladder.  The  gall- 
bladder forms  a  tumor  of  large  size  ;  fever,  sweating,  loss  of  flesh 
and  strength  are  developed  ;  localized  peritonitis  may  be  added. 
If  not  treated,  these  symptoms  will  continue  and  cause  the  death 
of  the  patient. 

Some  of  these  cases  may  be  cured  by  the  continuous  applica- 
tion of  cold,  others  by  aspiration,  while  in  others  it  is  necessary 
to  open  the  gall-bladder. 

3.  Such  a  calculus  may  be  followed  by  adhesions  between  the 
wall  of  the  bile-duct  and  the  intestine,  ulceration,  the  escape  of 
the  calculus  into  the  intestine,  and  the  recovery  of  the  patient. 
Or  the  calculus  may  remain  in  the  intestine  and  cause  an  ob- 
struction there. 

4.  One  or  more  calculi  may  remain  in  the  cystic  duct  for  years 
and  produce  attacks  of  pain  like  those  due  to  calculi  in  the  gall- 


238  THE   LIVER. 

bladder.     These  cases  have  been  successfully  treated  by  surgical 
operations. 

III.     CALCULI     MAY     PASS     FROM     THE     GALL-BLADDER     THROUGH     THE 
DUCTS    INTO    THE    INTESTINE. 

Such  a  passage  of  a  calculus  is  attended  with  symptoms  which 
are  called  an  attack  of  biliary  colic. 

The  cases  vary  as  to  the  size  and  consistence  of  the  calculi,  as 
to  whether  they  are  true  calculi  or  masses  of  inspissated  bile,  as 
to  the  rapidity  of  the  passage  of  the  calculi,  and  as  to  the  fre- 
quency of  the  attacks. 

Symptoms, — Sometimes  there  is  an  initial  chill,  more  or  less 
marked  ;  but  this  is  not  constant.  Then  comes  the  most  marked 
symptom — pain.  This  usually  comes  on  suddenly  and  severely, 
referred  to  the  epigastrium  and  the  lower  edge  of  the  liver,  and 
radiating  in  different  directions.  Occasionally  the  invasion  is 
slower,  and  the  pain  more  dull  and  aching.  The  pain,  as  such, 
resembles  that  of  intestinal  colic,  and  that  of  nephritic  colic. 

Nausea  and  vomiting  frequently  accompany  the  attack. 

Fever  occurs  in  three  ways  :  It  may  simply  accompany  the 
attack.  It  may  be  due  to  a  complicating,  localized  peritonitis. 
It  may  be  due  to  pre-existing  malarial  poisoning. 

During  an  attack  of  biliary  colic,  the  pulse  is  usually  small 
and  feeble  ;  the  bowels  are  constipated  before  and  during  the 
attack  ;  the  intestines  are  distended  with  gas. 

Usually  the  general  condition  of  the  patient  remains  good, 
but  there  may  be  marked  prostration  and  even  collapse  and 
death. 

Jaundice  is  regularly  developed  within  twenty-four  hours  after 
the  commencement  of  the  pain,  and  continues  for  some  days 
after  this  has  subsided.  But  when  the  calculi  are  small,  or  in- 
spissated bile  is  passed,  the  jaundice  may  be  entirely  absent.  In 
patients  who  have  repeated  attacks  of  severe  pain  referred  to 
the  upper  part  of  the  abdomen  without  jaundice  it  is  often  very 
difficult  to  tell  whether  the  pain  belongs  to  the  bile-duct,  the 
colon,  or  the  stomach. 

The  liver  may  be  swollen  and  tender  during  and  after  the  par- 
oxysm. The  gall-bladder  may  be  swollen,  tender,  and  sometimes 
surrounded  by  a  localized  peritonitis. 

Duration, — The  ordinary  attacks  only  last  for  a  few   hours  or 


'I'HE    LIVER.  239 

days.  There  may  be  only  one  or  two  attacks,  or  the  attacks  are 
repeated  at  intervals  for  a  number  of  years.  With  such  a  repe- 
tition of  the  attack  the  general  health  may  suffer,  partly  from 
the  recurrence  of  the  pain,  partly  from  the  drugs  used  to  con- 
trol it. 

Less  frequently  there  are  attacks  which  last  for  weeks  or 
months.  The  pain,  jaundice,  and  vomiting  continue,  there  is  an 
irregular  febrile  movement,  and  the  patients  lose  flesh  and 
strength. 

Diagnosis. — The  regular  attacks  with  pain  and  jaundice  are 
easily  recognized. 

Repeated  attacks  of  pain  in  the  upper  part  of  the  abdomen 
may  be  due  to  the  passage  of  a  calculus  through  the  ducts,  to  the 
presence  of  calculi  in  the  ducts  or  in  the  gall-bladder,  and  to  dis- 
orders of  the  colon  or  of  the  stomach  ;  it  is  often  very  difficult  to 
distinguish  between  them. 

Treatment. — During  the  paroxysm  of  biliary  colic  the  pain  is 
to  be  relieved  by  hypodermic  injections  of  morphine,  or  by  in- 
halations of  chloroform  or  ether.  There  seems  also  to  be  some 
advantage  in  the  use  of  hot  baths,  hot-water  enemata,  and  purga- 
tives. 

To  prevent  the  recurrence  of  attacks  of  biliary  colic  there 
are  plans  of  treatment  which  are  not  very  rational,  but  yet  which 
are  often  efficacious. 

In  some  patients  the  attacks  will  cease  if  the  stomach  is 
washed  out  every  day. 

In  some  patients  the  use  of  olive-oil  stops  the  attacks.  Half 
a  pint  can  be  poured  into  the  stomach  through  the  stomach-tube  ; 
or  a  tablespoonful  of  oil  can  be  mixed  with  milk  and  swallowed, 
the  second  day  two  tablespoonfuls  of  oil  are  taken,  and  so  on  up 
to  six  tablespoonfuls. 

The  sulphate,  chlorate,  phosphate,  or  salicylate  of  soda  seem 
to  cure  some  cases,  as  do  also  the  alkaline  waters  of  Carlsbad 
and  Vichy. 

If  the  attacks  are  frequently  repeated  and  cannot  be  other- 
wise relieved  a  surgical  operation  is  necessary. 


240  THE   LIVER. 


IV.    CALCULI    MAY    PASS    FROM    THE    GALL-BLADDER    INTO    THE    COM- 
MON   DUCT    AND    BECOME    IMPACTED. 

The  patients  give  the  history  of  one  or  more  attacks  of  biliarv 
colic,  or  that  of  several  attacks  of  pain  and  light-colored  faeces 
without  jaundice.  Then  there  comes  an  attack  of  biliary  colic 
which  lasts  for  a  time  and  subsides,  but  the  jaundice  continues 
and  increases. 

There  are  cases,  however,  in  which  there  is  no  attack  of  pain 
to  mark  the  time  of  the  lodgement  of  the  calculus.  On  some 
particular  day  it  is  evident  that  the  common  bile-duct  is  ob- 
structed, and  the  symptoms  of  this  obstruction  become  more 
and  more  decided. 

The  skin  becomes  very  yellow,  the  urine  is  dark  with  bile 
pigment,  the  faeces  are  white.  There  is  an  irregular  fever,  the 
patients  lose  flesh  and  strength  ;  there  are  loss  of  appetite,  nau- 
sea, and  vomiting;  the  bowels  are  constipated,  the  tongue  is 
brown  and  dry,  cerebral  symptoms  are  developed,  and  there  are 
bleedings  from  the  mucous  membranes  and  into  the  skin.  The 
liver  may  be  large  and  tender  and  the  gall-bladder  distended. 

Unless  relieved  by  a  surgical  operation  this  condition  regu- 
larly proves  fatal,  but  it  is  possible  for  the  calculus  to  escape  by 
a  perforation  into  the  intestine,  and  for  the  patient  to  recover. 

The  only  treatment  is  a  surgical  operation  to  remove  the 
calculus. 

V.    CALCULI    MAY    PASS    FROM    THE    GALL-BLADDER    INTO    THE    COMMON 
DUCT    AND    REMAIN    THERE    WITHOUT    BEING    IMPACTED. 

Such  a  calculus  passes  into  the  common  duct  and  remains 
there.  Then  for  years  the  calculus  slowly  increases  in  size,  and 
the  common  and  hepatic  duct  become  dilated  to  make  room 
for  it. 

The  patients  suffer  from  repeated  attacks  of  pain,  fever,  nau- 
sea, vomiting,  and  jaundice.  These  attacks  become  more  fre- 
quent and  the  patients  cease  to  improve  between  the  attacks. 
The  jaundice  becomes  continuous,  they  lose  flesh  and  strength, 
and  finally  die  exhausted,  or  with  suppurative  inflammation  of 
the  gall-bladder  or  bile-duct. 

The  only  efficient  treatment  is  by  a  surgical  operation. 


THE   LIVER.  241 


VI.    CALCULI    IN    THE    INTESTINE. 


A  calculus  of  some  size,  situated  in  the  gall-bladder,  may- 
cause  inflammation  of  the  wall  of  the  gall-bladder,  adhesions  to 
the  intestine,  perforation,  and  escape  of  the  calculus  into  the 
intestine. 

These  morbid  processes  are  naturally  attended  with  symp- 
toms, but  it  sometimes  happens  that  the  patient  will  give  no  his- 
tory of  them. 

After  a  time  the  calculus  is  increased  in  size  by  the  depo- 
sition about  it  of  successive  layers  of  mucus  and  of  the  salts  of 
lime. 

Such  a  calculus  may  remain  in  the  intestine  for  a  long  time 
without  any  symptoms,  except  occasional  uncomfortable  feelings 
in  the  abdomen.  It  may  produce  attacks  of  severe  pain.  It  may 
cause  partial  or  complete  obstruction  of  the  intestine. 

The  only  treatment  is  the  removal  of  the  calculus  by  a  sur- 
gical operation. 


THE    KIDNEYS. 


The  Movable  Kidney. 

It  not  infrequently  happens  that  one,  or  sometimes  both,  Icid- 
neys  cease  to  be  imbedded  in  the  fat  of  the  lumbar  region  and 
become  capable  of  a  liberty  of  motion  which  increases  as  time 
goes  on.  The  kidney  continues  to  be  fastened  by  its  large  blood- 
vessels, and  pushes  the  peritoneum  in  front  of  it. 

It  is  believed  that  such  a  movable  condition  of  the  kidney 
may  be  either  congenital  or  acquired.  It  occurs  more  frequently 
in  women,  in  women  who  have  borne  children,  among  the  labor- 
ing classes,  and  in  persons  between  the  ages  of  twenty-five  and 
forty  years.  The  right  kidney  is  the  one  most  frequently  af-i 
fected,  next  the  left  kidney,  least  often  both  kidneys. 

Symptoms. — We  can  only  be  certain  of  the  existence  of  a 
movable  kidney  when  we  are  able  to  distinctly  feel  it.  It  feels 
like  a  solid  tumor,  not  as  hard  as  the  spleen,  of  the  shape  of  the 
kidney,  movable,  easily  escaping  from  the  hand  which  tries  to 
grasp  it,  easily  pushed  back  into  its  natural  position.  In  order 
to  make  out  such  a  kidney  it  is  necessary  to  put  the  patient  into 
different  positions,  so  as  to  displace  the  organ  ;  it  is  often  neces- 
sary to  examine  on  several  different  days  before  we  can  be  sure 
of  it. 

Such  a  movable  condition  of  the  kidney  may  never  cause  any 
discomfort,  and  the  patient  may  remain  entirely  unconscious  of 
its  existence.  In  other  cases,  however,  the  abnormal  position  of 
the  kidney  gives  rise  to  a  variety  of  symptoms. 

Perhaps  the  most  ordinary  state  of  affairs  is  for  the  patient 
either  to  suffer  from  pain  in  the  back,  or  to  discover  that  he  has 
an  abdominal  tumor. 

The  pain   in   the  back   is  referred   to  the   side  on  which   the 


2  50  THE    KIDNEYS. 

kidney  is  displaced.  It  is  a  severe  pain,  made  worse  by  the 
erect  position.  The  real  cause  of  the  pain  is  often  overlooked 
for  a  long  time. 

The  discovery  of  an  abdominal  tumor  naturally  fills  the  pa- 
tient with  alarm,  and  so  may  give  rise  to  a  variety  of  nervous 
phenomena  for  which  the  displacement  of  the  kidney  can  hardly 
be  held  responsible. 

Less  frequently  the  variety  of  symptoms  is  greater.  There 
are  feelings  of  dragging,  of  pressure,  or  of  weight  in  the  abdo- 
men. There  may  be  nausea,  vomiting,  and  pain  in  the  abdo- 
men. Intense  pains  may  radiate  toward  the  epigastrium,  the 
sacral  and  lumbar  region,  the  intercostal  spaces,  the  shoulders, 
along  the  ureter,  into  the  testicle  or  the  labia  majora. 

It  is  said  that  there  may  be  attacks  of  localized  peritonitis 
around  the  displaced  kidney,  with  chills,  fever,  intense  pain,  and 
hardness  and  tenderness  of  the  abdomen. 

The  pelvis  of  the  displaced  kidney  may  become  imflamed,  or 
may  contain  calculi. 

By  the  bending  of  the  ureter  there  may  be  produced  either 
temporary  or  permanent  hydronephrosis. 

Treatment  is  called  for  only  in  those  patients  in  whom  the 
displacement  of  the  kidney  gives  well-marked  symptoms.  The 
simplest  plan  is  to  keep  the  patients  in  bed  on  their  backs  for  a 
month,  and  then  to  let  them  go  about  with  a  binder  and  pad  so 
contrived  as  to  keep  the  kidney  in  place. 

If  the  patient  cannot  be  relieved  in  this  way,  a  surgical  opera- 
tion becomes  necessary.  The  offending  kidney  may  be  entirely 
removed,  or  it  may  be  fastened  in  its  proper  place  by  sutures. 


Classification  of  Diseases  of  the  Kidney. 

The  recognition  of  the  diseases  of  the  kidney,  which  still  bear 
tlie  name  of  their  discoverer,  dates  back  only  to  the  year  1827, 
when  Richard  Bright  published  his  first  paper  on  the  subject. 
This  first  paper  was  followed  by  others,  and  in  1829  Christison 
published  in  the  Edi7ibitrgh  Medical  and  Surgical  Review  his  account 
of  the  same  disease.  Both  these  authors  regarded  the  disease  as 
a  morbid  change  in  the  kidneys,  which  was  the  cause  of  the  ac- 
companying symptoms. 

In    1841    Rayer  completed   his   large  atlas  of  colored  plates 


THE   KIDNEYS.  25  I 

and  description  of  kidney  diseases.     His  classification  is  as  fol- 
lows : 

1.  Nephritis — an  inflammation  of  the  cortical  or  tubular  por- 
tion of  the  kidneys. 

[a)  Simple  nephritis. 
(^)   Gouty  nephritis. 

(c)  Rlieumatic  nephritis. 

(d)  Nepliritis  produced  by  poison. 
((?)  Albuminous  nephritis. 

2.  Pyelitis. 

3.  Perinephritis. 

In  1842  Rokitansky  recognized  the  waxy,  or  amyloid,  kidneys 
as  presenting-  different  lesions  from  those  found  in  otlier  exam- 
ples of  kidney  disease. 

In  185 1  Frerichs  published  his  monograph  on  Bright's  dis- 
ease, and  gave  a  systematic  description  whicli  has  had  a  decided 
effect  on  the  minds  of  most  subsequent  observers.  His  concep- 
tion is  that  of  one  disease — Bright's  disease,  with  a  characteristic 
lesion — inflammation  of  the  kidneys.  The  varieties  of  the  dis- 
ease depend  upon  the  stages  of  the  inflammation.  There  are 
tliree  stages  : 

1.  The  stage  of  hyperaemia  and  of  commencing  exudation. 

2.  The  stage  of  exudation  and  of  commencing  transformation 
of  the  exudation. 

3.  The  stage  of  atrophy. 

1.  Hyper(zmia. — ^The  first  stage  is  characterized  by  an  increase 
in  the  size  of  the  kidneys,  especially  of  the  cortex,  by  general 
congestion,  by  extravasation  of  blood  in  the  Malpighian  bodies, 
the  tubes,  and  the  kidney  tissue,  and  by  filling  of  the  tubes  witli 
coagulated  fibrin.     The  epithelium  of  the  tubes  is  unaltered. 

2.  Exudation. — In  the  second  stage,  the  congestion  diminishes 
while  the  exudation  increases.  The  exudation  is  found  in  the 
tubules  and  in  the  interstitial  tissue.  Tlie  exudation  between 
the  tubes  is  sometimes  organized  into  connective  tissue.  The 
cortex  becomes  of  a  white-yellowish  color,  and  remains  thickened. 
The  surface  of  the  kidney  is  smooth  or  slightly  granular.  The 
pyramids  are  of  a  reddish  color.  Some  of  the  Malpighian  bodies 
are  normal,  others  are  enlarged  and  filled  with  exudation.  In 
the  cortex  the  epithelium  of  the  tubes  is  swollen  and  granular, 
and  may  break  down  altogether,  or  it  simply  shrivels  and  atro- 
phies.    The  tubes  are  filled  with  degenerated  epithelium,  granu- 


252  THE    KIDNEYS. 

lar  matter,  and  fat-globules,  or  with  homogeneous  exudation. 
The  tubes  are  dilated.  The  dilatation  of  the  tubes  is  the  princi- 
pal or  only  cause  of  the  increased  size  of  the  kidney. 

3.  Atrophy. — In  the  third  stage,  the  kidneys  are  smaller,  or  of 
normal  size,  or  even  larger  than  normal.  The  capsule  is  ad- 
herent. The  surface  of  the  kidney  is  irregular  and  granular,  its 
color  a  dusky  yellow.  Its  consistence  is  hard.  The  cortex  is 
thinned.  The  pyramids  are  smaller.  The  fat  about  the  pelvis  is 
increased  in  amount.  The  tubes  are  dilated  and  filled  as  in  the 
second  stage,  or  are  collapsed  and  folded  together.  Most  of  the 
Malpighian  bodies  are  shrivelled  and  fatty.  If  the  exudation  be- 
tween the  tubes  has  become  organized,  we  find  masses  of  con- 
nective-tissue cells  and  fibres. 

This  description  of  the  lesions,  taken  as  it  was  from  nature, 
is  as  true  now  as  when  it  was  written.  But  yet  our  present 
pathological  knowledge  makes  us  interpret  these  lesions  some- 
what differently. 

In  1852  Dr.  George  Johnson  published  a  work  on  kidney  dis- 
eases which,  like  that  of  Frerichs,  has  had  a  durable  effect  on 
medical  opinions.    He  distinguishes  five  forms  of  Bright's  disease. 

1.  Acute  Desquamative  Nephritis. — The  form  of  disease  occur- 
ring after  scarlet  fever,  exposure  to  cold,  etc.  This  corresponds 
to  Frerichs's  first  stage.  Johnson,  however,  lays  most  stress  upon 
the  desquamation  of  the  epithelium,  and  but  little  on  the  exuda- 
tion in  the  tubes.  Exudation  between  the  tubes  he  does  not 
mention. 

2.  Chronic  Desquamative  Nephritis. — This  corresponds  to  the 
second  and  third  stages  of  Frerichs.  Johnson  describes  the  de- 
generation of  the  epithelium,  the  denudation  of  the  tubes  of  their 
epithelium,  their  dilatation  and  collapse,  and  the  presence  of  co- 
agulated material  within  them.  The  Malpighian  tufts  are 
thickened  or  atrophied.  The  arteries  are  thickened.  He  re- 
gards the  production  of  new  fibrous  tissue  as  an  accidental  and 
unessential  phenomenon.  ^ 

3.  Waxy  Degeneration  of  tJie  Kidney. — Under  this  name  John- 
son describes  kidneys  which  are  of  large  size,  their  cortex  thick 
and  white,  their  tubes  filled  with  waxy  material.  This  waxy  ma- 
terial he  supposes  to  be  produced  by  a  degeneration  of  the  epi- 
thelium. The  large  hyaline  casts  found  in  the  urine  he  calls 
waxy,  and  seems  to  consider  them  diagnostic  of  this  form  of  kid- 
ney disease. 


THE   KIDNEYS.  253 

4.  Acute  Non-dcs(juamative  Disease  of  the  Kidneys. — This  is  cliar- 
acterized  during  life  by  scanty  or  suppressed  urine,  but  contain- 
ing no  albumin,  and  no  casts,  or  only  a  few  waxy  ones.  The 
kidneys  are  of  normal  size  ;  the  epithelium  of  the  tubes  is  some- 
what altered. 

5.  Chronic  Non-desquamative  Disease. — The  kidneys  are  usually 
large,  very  rarely  atrophied.  The  cortex  is  tliick  and  white. 
The  convoluted  tubes  are  more  opaque  than  usual.  The  Mal- 
pighian  bodies  and  arteries  are  thickened. 

6.  The  Granular  Fat  Kidney. — This  form  may  be  a  consequence 
of  the  non-desquamative  disease,  of  acute  desquamative  inflam- 
mation, and  rarely  of  chronic  desquamative  disease.  The  kidneys 
£ire  large,  the  cortex  white,  mottled  with  yellowish  granulations. 
These  yellow  granulations  are  formed  of  tubes  containing  oil- 
globules.  The  vessels  and  Malpighian  bodies  are  thickened. 
Sometimes  the  same  yellow,  fatty  granulations  are  found  in 
atrophied  kidneys. 

7.  The  Mottled  Fat  Kidney. — All  the  tubes  of  the  cortex  con- 
tain oil-globules,  and  there  are  red  spots  of  congestion  or  extrav- 
asation. 

To  Traube  (1856)  belongs  the  merit  of  recognizing  chronic 
congestion  of  the  kidney  as  a  lesion  with  an  entirely  different 
cause  from  that  of  other  forms  of  Bright's  disease  ;  and  also  of 
calling  attention  to  the  fact  that  blood-contamination  cannot  be 
the  only  cause  of  the  cerebral  symptoms. 

In  1858  Virchow,  in  his  Cellular  Pathology,  developed  the 
doctrine  that  in  Bright's  disease  either  the  tubes,  the  stroma,  or 
the  Malpighian  bodies  are  principally  involved,  and  that  we  can, 
therefore,  distinguish  a  parenchymatous  nephritis,  an  interstitial 
nephritis,  and  an  amyloid  degeneration  of  the  kidney.  This 
doctrine  has  had  a  lasting  effect  on  all  subsequent  classifica- 
tions. 

Grainger  Stewart  distinguishes  : 

1.  The  Inflammatory  Form. — This  has  three  stages  :  (i)  That  of 
inflammation  ;  (2)  that  of  fatty  transformation  ;  (3)  that  of 
atrophy.  These  correspond  very  closely  with  the  three  stages 
described  by  Frerichs. 

2.  The  Waxy  Form. — This  also  has  three  stages  :  (i)  That  of 
simple  degeneration  of  the  vessels  ;  (2)  that  in  which  a  second- 
ary alteration  of  the  tubes  is  superadded  ;  (3)  that  of  atrophy. 

In  the  first  stage,  the  kidney  is  of  normal  size,  the  tubes  are 


254  THE   KIDNEYS. 

unaltered  ;  only  the  Malpighian  bodies  and  small  arteries  have 
undergone  waxy  degeneration. 

In. the  second  stage  the  kidney  is  enlarged,  the  cortex  thick 
and  white,  with  Malpighian  bodies  and  small  vessels  waxy  ;  the 
tubes  contain  hyaline  casts  ;  their  epithelium  is  swollen  ;  their 
basement  membrane  may  be  waxy. 

In  the  third  stage  the  kidnev  is  small.  The  surface  is  rough, 
•granular,  and  pale.  The  tubular  structures  are  swollen.  The 
tufts  and  vessels  are  waxy.  A  few  tubes  are  distended,  most  are 
collapsed,  and  are  represented  only  by  fibrous  tissues. 

3.  The  Cirrhotic^  or  Contracting  Form. — This  consists  of  an 
hypertrophy  of  the  connective  tissue  of  the  organ,  and  a  conse- 
.quent  atrophy  of  all  the  other  structures. 

There  is  at  first  little  diminution  in  the  size  of  the  organ,  but 
the  capsule  is  thickened  and  adherent,  and  the  surface  is  rough 
and  granular.  The  color  is  pale  and  reddish.  The  arteries  are 
prominent,  their  walls  thickened,  and  their  cavities  often  dilated- 
On  the  surface,  and  in  the  substance,  cysts  are  often  seen.  Some 
are  produced  by  dilatation  of  the  Malpighian  capsules,  some  by 
dilatation  of  the  tubes,  some  by  a  morbid  growth  of  epithelial 
elements.  The  tubes  are  compressed  and  atrophied  by  the  new 
fibrous  tissue.  They  contain  little  opaque  material,  but  often 
hyaline  matter.  Sometimes  urate  of  soda  is  found  in  the  stroma 
and  tubes  of  the  pyramids.  The  disease  is  a  non-inflammatory 
increase  of  connective  tissue. 

Both  the  waxy  and  contracting  forms  may  be  secondarily 
affected  with  the  inflammatory  disease. 

4.  Simple  Fatty  Degeneration. — The  kidneys  are  of  about  the 
normal  size.  The  surface  is  smooth,  the  capsule  not  adherent. 
Their  texture  is  soft,  the  cortex  is  pale  and  mottled,  with  seba- 
ceous-looking deposits.     The  epithelium  of  the  tubes  is  fatty. 

Dickinson  describes  tubal  nephritis,  granular  degeneration, 
and  depurative  infiltration  : 

1.  Acute  Tubal  Nephritis. — This,  the  nephritis  of  scarlet  fever 
and  of  exposure  to  cold,  is  described  in  ■very  much  the  same 
terms  as  the  acute  desquamative  nephritis  of  Johnson. 

2.  Chronic  Ttibal  Nephritis. — The  kidney  is  large,  the  cortex  of 
an  opaque  white  or  buff  color,  the  pyramids  pink.  The  surface 
is  smooth,  the  capsule  not  adherent.  The  convoluted  tubes  are 
distended  with  granular  and  fatty  epithelium  and  with  fibrinous 
exudation.     The  straight  tubes  are  packed  with  the  products  of 


THE   KIDNEYS.  255 

epithelial  growth,  while  others  contain  transparent  fibrin.  The 
tubes  are  not  changed,  save  as  regards  their  contents.  TheJVlal- 
pighian  bodies  are  noi"mal  or  somewhat  dilated.  There  is  no 
increase  of  inter-tubular  tissue.  These  kidneys  remain  large 
and  smooth  to  the  last,  unless  complicated  with  the  depurative 
change. 

Sometimes  the  cortex  is  sprinkled  with  white,  sharply  defined 
specks,  like  bits  of  bran.  This  change  is  characteristic  of  a  great 
amount  of  fatty  change  in  the  accumulated  epithelium. 

3.  Granular  Degeneration. — The  kidneys  may  be  of  normal  or 
even  increased  size,  but  are  usually  small.  The  capsule  is 
adherent.  The  surface  is  irregular  and  covered  with  little 
rounded  nodules.  The  cortex  is  thin.  Cysts  are  often  found  in 
the  cortex  and  cones.  There  is  an  increase  of  fibrous  tissue 
around  the  Malpighian  bodies  and  vessels,  and  beneath  the  cap- 
sule and  deeper  in  the  cortex.  The  cortical  tubes  are  atrophied 
or  dilated,  but  many  tubes  may  remain  unchanged.  The  tubes 
may  be  filled  with  epithelium,  or  with  transparent,  fibrinous 
material.  In  the  majority  of  cases  the  epithelium  is  exactly 
such  as  is  found  in  normal  kidneys.  When  changed,  it  is  by  an 
alteration  in  its  regularity  of  form,  becoming  somewhat  angular, 
as  if  cramped  in  growing  space.  The  circulation  through  the 
blood-vessels  is  much  obstructed.  The  formation  of  cysts  is  due 
to  dilatation  of  the  tubes  or  of  the  Malpighian  capsules. 

4.  Depurative  Infiltration. — The  kidney  is  at  first  of  normal  size, 
pale,  and  its  surface  smooth.  The  only  change  is  in  the  Malpi- 
ghian tufts,  which  react  with  iodine.  As  the  disease  goes  on, 
the  kidney  becomes  larger  and  its  capsule  adherent.  The  cortex 
is  of  a  pale,  opaque  fawn-color,  or  has  a  pinkish  or  gray  trans- 
lucency.  Afterward  the  kidney  atrophies  and  its  surface 
becomes  nodulated.  There  may  be  small  cysts.  In  cases  of  long 
standing,  almost  the  entire  organ  gives  the  characteristic  reac- 
tion with  iodine.  The  first  change  is  the  infiltration  of  the  Mal- 
pighian bodies  and  vessels.  Afterward  new  fibrous  tissue  is 
formed  between  the  tubes,  the  epithelium  degenerates,  the  tubes 
are  dilated  and  contain  fibrinous  casts. 

It  will  be  seen  that  the  name  of  "depurative  infiltration  "  is 
given  to  the  same  form  of  kidney  disease  which  is  called  by 
others  waxy  or  amyloid. 

Klebs  describes  : 

I.  Diffuse  Granular  Degeneration  of  the  Epithelium. — This   con- 


256  THE   KIDNEYS. 

dition  is  found  by  itself,  and  in  connection  with  lesions  in  the 
interstitial  tissue.  By  itself,  it  occurs  with  pyaemia,  phthisis, 
rheumatism,  typhoid  and  typhus  fevers,  the  malarial  fevers,  the 
acute  exanthemata,  extensive  burns,  poisoning  witli  phosphorus 
and  the  mineral  acids.  During  life  the  urine  may  contain  granu- 
lar casts  and  albumin.  The  kidney  is  somewhat  enlarged,  the 
cortex  grayish-yellow,  the  pyramids  bluish-red.  There  may  be 
little  extravasations  of  blood  in  the  convoluted  tubes.  The  epi- 
thelium of  the  tubes  is  granular  and  may  distend  them.  The 
tubes  may  contain  casts.  These  changes  are  most  frequent  in 
the  convoluted  tubes,  but  are  sometimes  confined  to  the  straight 
tubes  of  the  pyramids.  Tlie  entire  process  is  a  degenerative  and 
not  an  inflammatory  one. 

2.  Cyanotic  Induration  of  the  Kidneys.— T\\\?,  condition  is  pro- 
duced by  anv  long-continued  obstruction  to  the  escape  of  venous 
blood  from  the  kidneys,  most  frequently  by  heart  disease.  The 
kidneys  are  increased  in  size,  the  surface  smooth,  the  capsule  not 
adherent.  The  organ  is  hard,  the  cortex  and  pyramids  congested 
and  of  dark-red  color.  The  epithelium  of  the  tubes  is  not 
altered.  The  interstitial  tissue  is  harder,  but  not  increased  in 
amount.  The  continued  congestion  may,  after  a  time,  produce 
further  changes.  The  epithelium  of  the  convoluted  tubes  may 
imdergo  granular  degeneration,  and  the  cortex  becomes  paler. 
Or  there  may  be  an  increase  of  interstitial  tissue,  and  the  surface 
becomes  nodular. 

3.  Interstitial  Nephritis. — This  has  two  stages  :  (a)  That  of 
cell-infiltration  ;  {b)   that  of  atrophy. 

{a)  The  Stage  of  Cellular  Infiltration  of  the  Interstitial  Con- 
nective Tissue. — The  kidney  is  increased  in  size.  The  surface  is 
smooth,  the  capsule  not  adherent.  The  cortex  is  of  a  whitish  or 
yellowish  color,  the  pyramids  red.  In  the  cortex  the  tissue  be- 
tween the  tubes  is  everywhere  increased  from  two  to  four  fold. 
This  increase  is  due  to  the  presence  of  lymphatic  elements  and 
of  clear  serum.  There  is  at  first  an  exudation  of  lymphatic  fluid, 
which  dilates  the  lymphatic  vessels  of  the  interstitial  tissue,  and 
is  accompanied  by  an  emigration  of  white  blood-globules,  wliich 
finally  fill  all  the  spaces  in  the  interstitial  tissue.  The  epithelium 
of  the  convoluted  tubes  undergoes  granular  degeneration  in  con- 
sequence of  its  disturbed  nutrition.  The  increased  pressure  of 
blood  causes  an  exudation  of  the  elements  of  the  blood  from  the 
Malpighian  tufts,    namely,    fibrinogenic    material  which  coagu- 


THE    KIDNEYS.  2  5/ 

lates  in  tlie  tubes,  albumin,  and  red  blood-globules.  The  lym- 
phatic cells  perforate  the  basement  membrane  of  the  tubes  and 
become  adherent  to  the  fibrinous  cysts. 

(/;)  The  Stage  of  Atrophy. — The  preceding  stage  may  termi- 
nate in  resolution  and  recovery.  If  it  does  not,  it  is  succeeded 
either  by  a  hyperplasia  of  connective  tissue  or  by  granular 
atrophy. 

If  there  is  a  hyperplasia  of  connective  tissue,  the  kidneys  are 
of  normal  size,  or  slightly  atrophied.  The  capsule  is  somewhat 
adherent.  The  cortex  is  whitish,  yellowish,  or  mottled.  The 
pyramids  are  congested.  There  is  a  uniform  increase  of  connec- 
tive tissue  between  the  tubes.  The  tubes  are  unaltered  or  some- 
what narrowed. 

Granular  atrophy  is  more  common.  The  kidney  is  atrophied. 
The  capsule  is  very  adherent.  The  surface  is  uneven  and  nodu- 
lar. The  change  of  the  lymphatic  cells  into  connective  tissue  is 
accompanied  by  fatty  degeneration  of  the  cells.  In  the  atrophied 
spots  the  tubes  and  glomeruli  become  impervious.  The  tubes 
contain  hyaline  casts.  The  basement  membrane  of  the  atrophied 
tubes  becomes  thick  and  fibrous.  The  glomeruli  are  atrophied, 
their  capsules  thickened,  their  vessels  obliterated.  The  larger  ar- 
teries are  thickened. 

Glomerulo-nephritis. — Klebs  gives  this  name  to  a  form  of  dis- 
ease which  he  has  observed  in  scarlatina  cases.  The  kidneys  are 
of  medium  size,  the  capsule  not  adherent,  the  surface  smooth, 
the  parenchyma  congested.  There  are  no  changes  except  in  the 
glomeruli.  These  appear  as  opaque,  white  points.  On  minute 
examination,  it  is  found  that  there  are  large  numbers  of  small, 
rounded  cells  about  the  loops  of  the  Malpighian  tuft,  while  the 
epithelium  of  the  capsule  is  unaltered. 

Amyloid  degeneration  is  described  in  much  the  same  way  as 
b_y  other  authors. 

Rindfleisch  describes  : 

I.  Acute  Parenchymatous  Nephritis. — In  the  milder  form  the 
kidney  is  of  normal  size,  the  surface  smooth,  the  cortex  of  a  yel- 
lowish-gray color.  There  is  a  moderate  degree  of  cloudy  swell- 
ing of  the  epithelium  of  the  convoluted  tubes. 

In  the  severer  form  the  kidney  has  the  same  appearance,  but 
is  increased  in  size  and  the  cortex  is  thickened. 

Both  these  forms  occur  with  the  acute  exanthemata,  typhus 
fever,  pyaemia,  etc. 


258  THE    KIDNEYS. 

2.  Diffuse  Interstitial  Nephritis.  —  This  corresponds  very 
closely  with  the  description  given  by  Klebs. 

He  states  that  the  disease  mav  begin  as  a  parenchymatous  ne- 
phritis, and  afterward  become  interstitial,  but  that  tlie  two  forms 
also  occur  independently  of  eacli  other. 

Amyloid  degeneration  is  usually  accompanied  by  interstitial  ne- 
phritis. The  am3'loid  degeneration  is  the  primary  change,  and 
the  nephritis  follows  it  as  a  secondary  lesion. 

Rosenstein   describes  : 

1.  Chronic  Congestion  of  the  Kidney. — This  condition  is  described 
in  much  the  same  way  as  by  the  preceding  authors. 

2.  Catarrhal  Nephritis. — -The  kidney  is  of  normal  size,  or 
slightly  enlarged;  in  severe  cases  congested  and  mottled  with  small 
ecchymoses.  The  process  begins  at  the  npices  of  the  pyramids, 
which  are  at  first  congested,  afterward  pale.  After  a  time  we 
find  the  pyramids  divided  into  red  and  white  striae,  running  from 
the  apex  to  the  base  of  the  pyramids.  The  red  striae  are  the  por- 
tions more  recently  congested  ;  the  white  are  the  tubes  distended 
by  an  increase  of  epithelium. 

The  urine  contains  a  little  albumin,  hyaline,  granular,  and 
epithelial  casts  and  blood-globules. 

The  symptoms  during  life  are  not  marked.  The  lesion  is  sel- 
dom primary.  It  may  follow  catarrhal  inflammation  of  the  ure- 
thra, bladder,  or  ureters  ;  the  use  of  cantharides,  copaiba,  or 
cubebs,  typhoid  or  typhus  fever,  cholera,  etc. 

3.  Diffuse  Nephritis^  Parenchymatous  Nephritis,  Brighf s  Disease^ 
Granular  Degeneration  of  the  Kidney. — This  form  lias  three  stages. 

The  first  stage  is  that  of  hyperaemia.  The  kidney  is  of  nor- 
mal size,  or  enlarged,  congested,  and  red  ;  there  is  blood  in  the 
tubes,  and  the  epithelium  of  the  convoluted  tubes  is  swollen. 

The  second  stage  is  that  of  exudation.  The  kidney  is  en- 
larged, the  cortex  pale,  the  pyramids  red.  The  epithelium  of  the 
convoluted  tubes  is  swollen  and  granular.  The  tubes  are  dilated 
and  contain  casts.  There  is  usually  an  increase  of  cells  in  the 
interstitial  tissue. 

The  third  stage  is  that  of  atrophy.  The  kidney  becomes 
smaller,  its  surface  nodular.  The  atrophy  may  take  place  with- 
out any  change  in  the  interstitial  tissue,  simply  as  a  result  of  the 
destruction  of  the  epithelium.  Usually,  however,  the  retraction 
of  the  new  interstitial  tissue  assists  in  producing  the  atrophy. 

The  epithelium  is  granular  or  fatty.      The  Malpighian  bodies 


THE   KIDNEYS.  259 

are  atrophied,  their  capsules  thickened  and  surrounded  with  new 
connective  tissue.  The  basement  membranes  of  the  tubes  are 
thickened,  and  are  accompanied  by  bands  of  connective  tissue. 
The  intertubular  capillaries  are  partly  dilated,  partly  small  and 
fatty. 

The  atrophy  consists,  therefore,  in  a  suppression  of  the  func- 
tion of  a  number  of  the  tubes,  with  obliteration  of  sonic  of  the 
blood-vessels  and  increase  of  the  interstitial  tissue. 

Either  process,  that  in  the  ejjithelium  or  that  in  the  connec- 
tive tissue,  can  occur  separately,  but  they  are  usually  combined. 

4.  Amyloid  Degeneration. — Rosenstein  describes  this  form  in 
much  the  same  way  as  other  authors.  He  regards  the  degenera- 
tion of  the  vessels  only  as  a  complication  of  the  parenchymatous 
and  interstitial  change. 

5.  The  Fatty  Kidney. — There  is  an  infiltration  of  the  epithelium 
with  fat,  or  a  fatty  degeneration.  The  condition  is  described  in 
tlie  same  way  as  the  diffuse  granular  degeneration  of  Klebs. 

Weigert  divides  Bright's  disease  into  parenchymatous  degen- 
eration and  true  nephritis.  He  does  not  distinguish  between  in- 
terstitial and  parenchymatous  forms  of  nephritis,  but  believes 
that  in  all  cases  the  disease  begins  with  degeneration  of  the  epi- 
thelium, which  is  followed  by  inflammatory  interstitial  processes. 

Gull  and  Sutton  have  shown  very  clearly  the  frequency  with 
which  changes  in  the  arteries  and  capillaries — arterio-capillary 
fibrosis— are  associated  with  the  atrophic  form  of  Bright's  dis- 
ease ;  and  that  these  changes  in  the  arteries  and  capillaries  may 
also  exist  and  give  symptoms  without  any  lesions  of  the  kidneys. 
From  these  facts  they  have  drawn  the  conclusion  that  this  form 
of  Bright's  disease  is  not,  properly  speaking,  a  disease  of  the  kid- 
neys, but  rather  one  of  the  arteries  and  capillaries. 

Bartels  uses  the  name  of  "  The  Diffuse  Diseases  of  the  Kid- 
neys," with  the  subdivisions  of  H)'peraemia,  Ischsemia,  Acute 
Parenchymatous  Nephritis,  Chronic  Parenchymatous  Nephritis, 
Renal  Cirrhosis,  and  Amyloid  Degeneration. 

Active  hyper cetnia  is,  he  says,  a  condition  which  arises  slowly 
as  the  result  of  some  toxic  influence,  most  frequently  from  the 
use  of  cantharides.  Apparently  he  has  little  or  no  personal  ex- 
perience of  the  anatomical  changes  found  in  the  kidneys. 

Passive  hypercemia  is  the  same  condition  as  that  also  called 
"chronic  congestion  of  the  kidney,"  and  cyanotic  induration  of 
the  kidney.     Its   most  important  form   is  that  due   to  valvular 


26o  THE   KIDNEYS. 

lesions  of  the  heart  and  to  certain  affections  of  the  lungs.  He 
makes  no  new  statement  concerning  the  pathological  changes. 

Ischcemia  is  the  condition  of  more  or  less  complete  stoppage 
of  the  arterial  blood-supply  to  the  kidneys,  occurring  independ- 
ently of  congestion  of  the  nervous  system.  It  occurs  only  in  the 
asphyxia  stage  of  cholera. 

Acute  Parenchymatous  NepJwitis. — Under  this  name  Bartels  in- 
cludes all  the  cases  of  acute  Bright's  disease.  He  says  that  the 
only  essential  and  constant  microscopical  appearances  are  the 
changes  in  the  epithelium  of  the  tubes.  The  epithelial  cells  are 
swollen  and  cloudy,  they  are  infiltrated  with  granules  of  fat,  and 
are  broken-down.  To  these  changes  in  the  epithelium  are  fre- 
quently added  a  swelling  and  infiltration  of  the  stroma,  casts  in 
the  tubes,  and  extravasations  of  blood. 

Chronic  Pa7'encliymatous  NepJiritis. — This  may  follow  acute  par- 
enchymatous inflammation,  or  may  begin  as  a  chronic  process. 
The  kidneys  are  large,  white,  and  smooth.  The  tubes  are 
dilated  ;  the  epithelium  is  only  partly  preserved,  and  the  cells 
which  remain  are  large,  granular,  and  fatty.  In  many  places  the 
epithelium  is  completely  gone  and  in  its  stead  the  tubes  are  en- 
tirely filled  with  masses  of  detritus  mixed  with  oil-globules ; 
casts  are  found  in  many  of  the  tubes.  The  stroma  is  thickened 
by  fluid  exudation,  by  an  emigration  of  white  blood-cells,  and  by 
a  growth  of  new  connective  tissue.  The  small  arteries  and  Mal- 
pighian  tufts  are  often  the  seat  of  waxy  degeneration. 

Renal  Cirrhosis. — The  kidne}''  is  very  much  diminished  in  size, 
especially  the  cortex.  This  diminution  in  size  is  due  to  the 
wasting  of  the  glandular  tissue,  while  at  the  same  time  there  is  an 
extensive  growth  of  new  fibrous  tissue.  The  cliange  in  the  kid- 
ney is  due  to  a  primary  growth  of  the  intertubular  connective  tis- 
sue, and  this  leads  to  the  dwindling  of  the  substance  of  the  gland, 
a  wasting  preceded  by  no  inflammatory  swelling  of  the  organ. 

To  Cohnheim  belongs  the  merit  of  drawing  attention  to  the 
importance  of  the  glomeruli  in  acute  nephritis,  and  to  the 
changes  which  are  found  in  them.  He  also  points  out  clearly 
that  well-marked  symptoms  of  acute  nephritis  may  exist  during 
life,  although  no  structural  changes  are  found  in  the  kidneys 
after  death. 

Langhans,  Nauwerck,  and  Friedlandler  have  developed  still 
further  the  doctrine  of  gloraerulo-nephritis,  and  have  described 
in  detail  the  lesions  found  in  the  glomeruli. 


THE   KIDNEYS.  261 

Ziegler  describes  : 

1.  Glonierulo-nepJiritis,  occurring  either  by  itself  or  combined 
with  changes  in  the  epithelium  of  the  tubes,  or  witli  exudation  of 
inflammatory  products  into  the  stroma. 

2.  Chronic  Parcncliyniatous  Nephritis. — The  common  feature  of 
this  form  of  nephritis  is  that  tliere  is  a  continuous  inflammatory 
exudation  from  the  blood-vessels,  and  that  changes  go  on  in  the 
epithelium  of  the  kidney. 

As  subdivisions  of  parenchymatous  nephritis  he  distinguishes  : 
The  inflammatory,  fatty  kidney  ; 
Chronic  hemorrhagic  nephritis  ; 
Chronic  glomerulo-nephritis. 

3.  Chronic  Indurative  Nephritis. — The  inflammation  leads  to  a 
new  growth  of  connective  tissue  in  the  stroma,  and  an  atrophy  of 
the  tubes  'and  the  glomeruli. 

4.  The  Arteriosclerotic  Contracted  Kidney. — In  this  the  changes 
begin  in  the  walls  of  the  arteries  ;  they  are  thickened,  their 
lumen  is  narrowed  or  obliterated.  As  a  result,  smaller  or  larger 
numbers  of  glomeruli  become  atrophied,  with  the  kidney  tissue 
belonging  to  them.      The  stroma  is  not  much  thickened. 

Cornil  remarks  that  the  expression  of  Bright's  disease  ap- 
plied to  the  kidney  has  nowadays  no  more  value  than  the  ex- 
pression of  dyspepsia  applied  to  the  pathology  of  the  stomach  or 
of  asystolie  applied  to  the  pathology  of  the  heart.  He  distin- 
guishes : 

1.  Granular  alteratioti  of  the  renal  epithelium — a  common  lesion 
found  in  different  forms  of  hyperaemia,  especially  in  those  symp- 
tomatic of  the  infectious  diseases. 

2.  Fatty  degeneration,  which  is  secondary  to  the  chronic  diseases. 

3.  Chronic  congestion  of  the  kidney,  due  to  mechanical  disturb- 
ances of  the  circulation. 

4.  Diffuse  nephritis,  in  wliich  all  the  anatomical  elements  of 
the  kidney  are  involved. 

(a)  Acute  nephritis  with  predominance  of  congestive  and  in- 
flammatory phenomena. 

{b)  Acute  nephritis  with  predominance  of  diapedesis. 

((f)  Acute  nephritis  with  pi'edominance  of  degenerative  lesions. 

{d)  Nephritis  with  predominance  of  the  lesions  of  the  glome- 
ruli. 

(e)  Nephritis  witii  predominance  of  lesions  of  the  epithelium. 

(_/)  Nephritis  with  predominance  of  lesions  of  the  stroma. 


262  THE    KIDNEYS. 

5.  Systematic  nepht^itis,  in  which  from  the  first  tlie  lesion  in- 
volves exclusively  one  of  the  elements  of  the  kidney. 

[a)  Epithelial  cirrhosis  of  the  kidney.  A  chronic  degenera- 
tion of  the  renal  epithelium  with  atrophy  of  certain  systems  of 
tubes  and  glomeruli. 

ib)  Vascular  cirrhosis — a  true  interstitial  inflammation  of  the 
kidney  with  endarteritis  of  the  renal  arteries. 

All  of  Cornil's  anatomical  descriptions  are  very  true  to  nature, 
but  his  classification  is  not  one  adapted  to  clinical  purposes. 

As  we  look  back  over  the  history  of  the  disease,  it  is  easy  to 
recognize  the  points  of  difference  and  the  progress  which  has 
been  made. 

From  the  very  first  we  find  authors  looking  at  the  disease 
from  two  points  of  view  :  that  of  the  symptoms  and  that  of  the 
lesions.  So  that,  while  some  regard  Bright's  diseasfe  as  a  ne- 
phritis with  its  attendant  symptoms,  others  regard  it  as  a  disease 
of  the  blood,  or  of  the  arteries  and  capillaries,  with  which  a  ne- 
phritis may,  or  may  not,  be  associated. 

At  the  time  when  Frerichs  wrote,  it  was  customary  to  regard 
a  great  many  morbid  conditions  as  of  an  inflammatory  character, 
and  to  think  that  every  inflammation  went  regularl)'-  through 
three  stages.  So  we  find  Frericlis  arranging  all  the  lesions  of- 
Bright's  disease  as  belonging  to  the  stages  of  congestion,  exuda- 
tion, and  contraction  of  a  nephritis,  and  teaching  that  all  the 
forms  of  acute  and  chronic  Bright's  disease  were  different  stages 
of  one  and  the  same  morbid  process. 

Then  we  find  in  England,  first  Johnson,  and  then  Dickinson, 
referring  most  of  the  kidney  lesions  to  changes  in  tlie  epithelium 
of  the  tubes.  Here,  again,  it  soon  became  evident,  that  although 
changes  in  the  epithelium  exist  and  are  of  importance,  yet  John- 
son and  his  school  had  taken  too  one-sided  a  view  of  the  sub- 
ject. 

That  in  some  cases  of  Bright's  disease  there  is  waxy  degenera- 
tion of  the  walls  of  the  arteries  and  Malpighian  tufts  was  early 
recognized  bv  Rokitansky.  As  these  kidneys  have  been  more 
studied,  it  has  been  found  that  there  may  be  : 

1.  Waxy  degeneration  of  the  arteries  and  glomeruli,  without 
any  change  in  the  other  parts  of  the  kidneys  or  any  disturbance 
of  its  functions. 

2.  Waxy  degeneration  of  the  arteries  and  tufts,  followed  by 
chronic  changes  in  the  rest  of  the  kidneys.  ^ 


THE   KIDNEYS.  263 

3.  Waxy  degeneration  of  the  arteries  and  tufts,  forming  an 
unimportant  part  of  a  chronic  nephritis. 

The  next  step  forward  was  tlie  recognition  by  Traube  of  the 
condition  of  chronic  congestion  of  the  Icidney,  its  dependence  on 
heart  disease,  and  its  termination  in  changes  in  the  structure  of 
the  kidney. 

Then  we  find  an  attempt  by  Grainger  Stewart  to  go  bade  to 
Frerichs's  classification  of  an  inflammation  in  three  stages,  but 
separating  the  waxy  and  the  cirrhotic  kidneys. 

Among  English  writers  we  find  a  disposition  to  class  the  kid- 
neys according  to  their  gross  appearance,  and  to  speak  of  the 
large  white  kidney  and  the  contracted  kidney,  and  to  regard  the 
cirrhotic  kidney  as  not  inflammatory.  In  England,  also,  we  find 
especial  attention  drawn  to  the  condition  of  the  arteries  and 
capillaries  in  the  kidneys  and  in  the  rest  of  the  body  as  a  cause 
of  the  kidney  lesions  and  of  the  symptoms. 

The  next  step  forward  was  the  recognition  of  the  clianges  in 
the  glomeruli,  first  by  Klebs,  then  by  Cohnheim,  Friedliinder, 
and  others. 

At  the  same  time  there  has  been  an  attempt,  especially  in 
Germany,  to  class  together  the  changes  in  the  epithelium,  the 
exudation  of  inflammatory  products,  and  the  formation  of  new 
connective  tissue  under  the  one  head  of  parenchymatous  inflam- 
mation, teaching  that  the  morbid  process  originates  in  the  epi- 
thelium, and  that  the  other  changes  are  secondary  to  this. 

Further  modifications  have  been  introduced  into  this  doc- 
trine of  parenchymatous  nephritis,  by  the  contention  that 
changes  in  the  epithelium  alone  are  not  of  inflammatory,  but  of 
degenerative,  nature.  Incidentally  Cohnheim  brings  out  well 
the  important  point  that,  with  well-marked  changes  in  the  urine 
and  constitutional  symptoms  we  may  find  no  structural  changes 
in  the  kidneys  ;  in  other  words,  that  the  morbid  changes  in  these 
.kidneys  must  have  been  confined  to  the  blood-vessels. 

With  Ziegler,  Cornil,  and  others  have  come  in  an  improved 
technique  and  an  exact  study  of  the  changes  in  the  kidney,  which 
have  given  us  a  much  moi'e  satisfactory  knowledge  of  the  le- 
sions. 

Although  so  much  has  been  done  in  the  study  of  the  le- 
sions of  Bright's  disease,  it  must  be  confessed  that  the  ideas  of 
the  profession  in  general  concerning  it  are  still  somewhat 
crude.  « 


264  THE   KIDNEYS. 

As  regards  acute  Bright's  disease,  we  often  find  the  belief  : 

Ttiat  tlie  kidneys  are  large,  and  either  white  or  congested  ; 
that  the  chief  change  is  in  the  epithelium  of  the  tubes,  which  is 
swollen  and  detached  and  blocks  up  the  tubes  ;  that  there  is  some 
change  in  the  glomeruli  which  allows  albumin  to  pass  through 
the  walls  of  the  capillaries  ;  that  the  patients  pass  too  little  urine  ; 
that  in  consequence  of  this  diminished  production  of  urine  there 
may  be  developed  dropsy  or  cerebral  symptoms  ;  that  the  chief 
object  of  treatment  is  to  make  them  pass  more  urine,  or,  failing 
this,  to  purge  or  sweat  them. 

As  regards  chronic  Bright's  disease,  it  is  generally  believed 
that  there  are  two  principal  forms  :  one,  in  which  the  kidney  is 
more  or  less  large  and  white,  while  during  life  there  is  dropsy 
and  much  albumin  in  the  urine  ;  and  one,  in  which  the  kidney  is 
more  or  less  contracted  and  red,  and  there  is  little  or  no  albumin 
in  the  urine,  and  little  or  no  dropsy. 

It  has  become  evident  to  many  careful  observers  that  there  is 
a  group  of  persons  who  are  more  liable  than  are  others  to  chronic 
productive  inflammation  in  different  parts  of  the  bod}'.  It  may 
be  the  lungs,  or  the  heart,  or  the  arteries,  or  the  liver,  or  the  kid- 
neys that  are  affected  ;  and  either  one  or  several  of  these  organs 
are  involved  at  the  same  time. 

The  liability  is  most  common  after  forty-five  years  of  age,  but 
is  by  no  mean  infrequent  in  younger  persons.  Unquestionably 
many  of  these  persons  are  gouty  ;  in  some  there  is  a  history  of 
chronic  alcoholism  ;  in  some  there  is  an  hereditary  history  ; 
many  of  them  suffer  from  disturbances  of  digestion,  many  of 
them  have  habitually  an  excess  of  urates,  or  oxalates,  or  occa- 
sional sugar,  or  albumin  in  the  urine. 

So  great  is  the  number  of  these  cases,  and  so  constantly  are 
these  persons  under  observation,  that  it  is  often  not  difficult  to 
recognize  that  an  individual  belongs  to  this  group  before  he  has 
developed  any  one  of  the  characteristic  inflammations.  We  can 
predict  beforehand  that  a  given  individual  will,  at  some  time,  de- 
velop emphysema,  or  chronic  endocarditis,  or  endarteritis,  or  cir- 
rhosis of  the  liver,  or  chronic  nephritis. 

Curiously  enough,  it  has  occurred  to  some  very  intelligent 
physicians  that  this  group  of  persons  are  really  all  suffering  from 
the  same  disease,  and  that  they  develop  the  characteristic  lesions 
as  the  result  of  the  disease.  They  propose  to  call  this  disease 
Bright's   disease.     According   to    this  view  a  person    can    have 


THE    KIDNEYS.  265 

Bright's  disease  while  the  kidneys  are  still  normal.  In  this  way 
have  come  in  the  terms  of  "  renal  inadequacy  "  and  of  the  "  pre- 
albuminuric  stage  of  Bright's  disease." 

There  can  be  no  question  that  this  group  of  cases  is  a  veiy  im- 
portant one,  and  it  is  quite  true  that  most  of  them  do  have  disease 
of  the  kidneys  before  they  die.  I  do  not  know  of  any  good  name 
to  designate  all  the  cases  of  this  kind,  but  I  do  not  think  we  have 
any  right  to  say  that  they  are  all  examples  of  one  disease.  Much 
more  probable  is  it  that  they  all  exhibit  the  effects  of  heredity, 
environment,  and  mode  of  life. 

There  is  a  well-marked  disposition  on  the  part  of  some  authors 
to  include  cases  of  chronic  inflammation  of  the  arteries  under  the 
name  of  Bright's  disease.  This  view  of  the  matter  is  clearly 
stated  by  Mahomed  in  Guy's  Hospital  reports  for  1880. 

He  says  :  "The  object  of  this  paper  is  to  prove  that  in  the 
earlier  stages,  and  in  most  cases  even  to  their  final  stage,  the 
urine  of  what  is  generally  known  as  chronic  Bright's  disease 
with  red  granular  kidney  is  most  commonly  perfectly  normal. 
More  than  this,  its  object  is  to  prove,  either  that  chronic  Bright's 
disease  is  not  a  renal  disease,  although  it  frequently  gives  rise  to 
a  renal  affection,  or  else  that  another  disease  must  be  recognized 
which  constantly  precedes  and  prepares  the  way  for  Bright's  dis- 
ease, which  may  be  called  arterio-capillary  fibrosis,  or  any  other 
name  that  may  be  preferred  to  it." 

The  cases  which  Mahomed  narrates  in  his  paper  seem  to 
be  cases  of  chronic  arteritis,  with  more  or  less  complicating  ne- 
phritis. 

In  the  present  state  of  our  knowledge  it  is  wiser  to  put  aside 
the  name  of  Bright's  disease  and  the  ideas  connected  with  it,  and 
look  for  a  classification  of  kidney  diseases  which  will  be  of  prac- 
tical clinical  use  and  anatomically  correct.  There  seem  to  be 
three  ways  in  which  we  can  classify  kidney  diseases  :  according 
to  their  causes,  according  to  the  part  of  the  kidney  involved,  or 
according  to  the  nature  of  the  morbid  process. 

To  classify  kidney  diseases  according  to  their  causes  is,  in 
the  present  state  of  our  knowledge,  simply  impossible.  If,  for 
example,  we  try  to  make  a  class  of  the  kidney  diseases  caused  by 
scarlet  fever,  we  find  that  the  poison  of  this  disease  produces 
three  kidney  lesions  Which  differ  from  each  other  clinically  and 
anatomically.  On  the  other  hand,  one  well-marked  form  of  acute 
nephritis  is  caused  by  scarlet  fever,  by  diphtheria,  by  pregnancy, 


266  THE   KIDNEYS. 

and  occurs  without  discoverable  cause.  That  all  forms  of  ne- 
phritis are  caused  by  irritating  substances  in  the  blood  is  very- 
probable  ;  that  different  quantities  of  the  same  poison  can  pro- 
duce different  forms  of  inflammation  has  been  demonstrated,  but 
we  are  still  very  far  from  being  able  to  construct  a  classification 
based  on  causes. 

To  classify  kidney  diseases  according  to  the  part  of  the  kid- 
ney principally  involved  is  very  natural  and  not  at  all  difficult. 
There  can  be  no  question  that  disease  of  the  epithelium,  of  the 
glomeruli,  of  the  stroma,  or  of  the  arteries  decidedly  predomi- 
nates in  different  sets  of  kidneys.  A  classification  on  this  basis 
is  anatomically  correct.  But  when  we  try  to  use  this  classifica- 
tion for  clinical  purposes  it  does  not  answer.  The  history  which 
I  have  already  given  of  anatomical  classifications  shows  this  only 
too  plainly.  A  classification  according  to  the  nature  of  the  mor- 
bid process  is  altogether  the  most  promising.  There  are  three 
morbid  processes  which  occur  in  nearly  every  part  of  the  body 
which  produce  definite  anatomical  changes,  cause  regular  clini- 
cal symptoms,  and  call  for  appropriate  methods  of  treatment. 
These  morbid  processes  are  congestion,  degeneration,  and  inflam- 
mation. 

Congestion,  whether  acute  or  chronic,  produces  an  accumula- 
tion of  blood  in  the  veins  and  capillaries  of  the  part  affected, 
causes  local  symptoms  and  disturbances  of  function,  and  is  to 
be  relieved  by  means  addressed  to  the  circulation  of  the  blood. 

Degeneration,  whether  acute  or  chronic,  produces  changes 
more  or  less  profound  in  the  parts  affected,  is  regularly  caused  by 
disturbances  of  circulation,  and  by  other  diseases  ;  produces  dis- 
turbances of  function  according  to  its  severity  ;  may  be  itself  a 
cause  of  inflammation,  and  can  be  but  little  affected  by  treat- 
ment. 

Tnflaniniation  is  attended  with  three  essential  features,  which 
may  occur  separately  or  together  :  an  escape  of  the  elements  of 
the  blood  from  the  vessels,  a  formation  of  new  tissue,  and  a  death 
of  tissue.  So  we  speak  of  exudative,  productive,  and  necrotic 
inflammations. 

{a)  Exudative  inflammation  is  of  short  duration,  leaves  behind 
it  no  permanent  changes  in  the  parts  affected,  is  sometimes  ac- 
companied by  the  growths  of  pathogenic  bacteria,  and  can  be 
favorably  affected  by  treatment. 

{b)  Productive    inflammation    runs    an    acute,    subacute,    or 


THE   KIDNEYS.  267 

chronic  course.  It  effects  permanent  changes  in  the  inflamed 
parts.  Its  acute  forms  are  very  apt  to  become  chronic.  There 
is  much  variety  as  to  the  relative  quantity  of  exudation  and  of 
new  tissue.     Pathogenic  micro-organisms  may  be  present. 

(c)  Necrotic  inflammation  is  characterized  by  the  addition  of 
death  of  tissue  to  an  inflammation  of  either  exudative  or  produc- 
tive type.  It  is  always  accompanied  by  the  growth  of  patho- 
genic bacteria. 

Applying  this  principle  of  classification  to  the  kidneys  we  can 
distinguish  : 

1.  Acute  congestion  of  the  kidney. 

2.  Chronic  congestion  of  the  kidney. 

3.  Acute  degeneration  of  the  kidney. 

4.  Chronic  degeneration  of  the  kidney. 

5.  Acute  exudative  nephritis. 

6.  Acute  productive  nephritis. 

7.  Chronic  nephritis  with  exudation. 

8.  Chronic  nephritis  without  exudation. 

9.  Suppurative  nephritis. 

10.  Tubercular  nephritis. 


THE    URINE. 


Quantity, 


In  healthy  adults  consuming  the  ordinary  quantities  of  fluids 
and  solids  the  daily  discharge  of  urine  is  1,250  c.c,  or  50  fluid 
ounces,  or  3  pints.  This  quantity  is  liable  to  a  considerable 
amount  of  variation  according  to  the  quantity  of  fluid  taken  and 
the  amount  of  perspiration. 

Complete  occlusion  of  the  pelves  of  the  kidneys  or  of  their 
ureters  leads  to  complete  suppression  of  urine.  It  is  not  that 
urine  is  formed  and  cannot  escape  on  account  of  the  occlusions, 
but  that  the  kidneys  cease  to  perform  their  functions.  Suppres- 
sion of  urine  is  always  fatal,  but  yet  can  be  borne  for  a  number 
of  days  almost  without  symptoms.  Sooner  or  later,  however, 
prostration,  delirium,  stupor,  and  the  typhoid  state  are  developed. 

Severe  injuries  and  surgical  operations,  especially  those  on 
the  urethra  and  bladder,  may  be  followed  by  a  suppression  of 
urine  which  is  often  fatal.  It  is  probable  that  this  suppression 
is  due  to  an  acute  congestion  of  the  kidneys.  Any  disturbance 
of  the  circulation  which  produces  either  acute  or  chronic  conges- 
tion of  the  kidneys  regularly  diminishes  the  quantity  of  urine. 
So  we  find  that  in  acute  and  chronic  congestion  of  the  kidney,  in 
acute  nephritis,  in  the  exacerbations  of  chronic  nephritis,  and  in 
attacks  of  contraction  of  the  arteries  the  quantity  of  urine  is 
notably  diminished. 

When  the  body  temperature  is  considerably  higher  than  the 
normal  the  urine  is  diminished  in  quantity. 

In  saccharine  diabetes  patients  pass  very  large  quantities  of 
urine,  the  kidneys  being  apparently  excited  to  increased  activity 
by  changes  in  the  composition  of  the  blood.  In  cases  of  insipid 
diabetes  the  quantity  of  urine  of  low  specific  gravity  is  large,  but 
it  is  not  determined  why  this  increase  takes  place. 

In  the  slow  forms  of  chronic  nephritis,  whether  with  or  with- 


THE   URINE.  269 

out  exudation,  it  is  tlie  rule  to  have  increased  quantities  of  urine 
of  low  specific  gravity,  the  quantity  being  especially  large  and  the 
specific  gravity  very  low  if  the  vessels  are  the  seat  of  waxy  de- 
generation. But  this  increased  production  of  urine  may  at  any 
time  be  checked  by  changes  in  the  heart's  action,  by  contraction 
of  the  arteries,  or  by  an  exacerbation  of  the  nephritis. 

Specific  Gravity. 

The  determination  of  the  specific  gravity  of  the  urine  gives 
us  the  relative  quantitv  of  its  solid  and  fluid  constituents.  To 
obtain  practical  information  on  this  point  it  is  necessary  to  ex- 
amine the  urine  passed  at  different  times  in  the  day  on  a  number 
of  days.  In  healthy  persons  and  under  ordinary  conditions,  the 
specific  gravity  ought  not  to  varv  much  from  1020.  It  seems  to 
be  generally  agreed  that  the  solid  portions  of  the  urine  are  ex- 
creted by  the  epithelium  of  the  convoluted  tubes  and  the  fluid 
portions  filtered  through  the  Malpighian  bodies.  We  would  ex- 
pect, therefore,  that  a  diminution  in  the  specific  gravity  would 
be  caused  by  changes  in  the  renal  epithelium,  and  a  diminution 
in  the  quantity  of  the  urine  by  atrophy  of  the  Malpighian  bodies. 
As  a  matter  of  fact,  the  kidneys  behave  differently.  Wlien  the 
morbid  changes  are  confined  to  the  epithelium,  as  in  acute  and 
chronic  degeneration,  the  specific  gravity  is  not  lowered  ;  when 
the  Malpighian  bodies  are  atrophied  in  chronic  nephritis  the 
quantity  of  urine  is  not  necessaril}^  diminished.  A  persistent  low 
specific  gravity  means  a  chronic  nephritis  with  a  large  produc- 
tion of  new  interstitial  connective  tissue,  or  with  waxy  degenera- 
tion of  the  blood-vessels;  or  it  means  insipid  diabetes.  In 
chronic  nephritis  the  specific  gravity  remains  low  even  if  the 
quantity  of  urine  is  very  much  diminished.  But  in  insipid  dia- 
betes the  specific  gravity  rises  as  the  urine  is  diminished  in 
quantity. 

An  increase  in  the  specific  gravity  regularly  accompanies 
saccharine  diabetes  and  chronic  congestion  of  the  kidneys. 

Constituents,  Normal  and  Adventitious. 

Urea. — The  most  important  of  the  solid  constituents  of  the 
urine  is  lirea,  of  which  a  healthy  adult  excretes  every  day  about 
500  grains.     While  the  specific  gravity  of  the  urine  gives  a  gen- 


2/0  THE    URINE. 

eral  idea  of  the  relative  quantity  of  urea,  yet  there  are  sources  of 
error.  It  is  best  to  get  the  whole  daily  excretion  of  urea  for 
several  days  by  the  hypobromite  method.  The  principal  impor- 
tance of  this  is  in  determining  the  prognosis  of  cases  of  chronic 
nephritis.  When  the  daily  excretion  of  urea  is  much  below  the 
normal  the  prognosis  is  bad,  although  the  patients  may  seem  to 
be  doing  well. 

Urates,  Oxalates,  and  Phosphates. — The  presence  of  an  excess 
of  uric  acid,  of  the  urates,  of  oxalate  of  lime,  and  of  the  phos- 
phates are  of  importance,  not  because  they  indicate  disease  or 
disturbance  of  functions  of  the  kidneys,  but  because  they  show 
disordered  digestion  and  an  abnormal  condition  of  the  blood. 
There  are  many  cases  of  kidney  disease  in  which  tlie  treatment 
of  these  disturbances  is  of  the  greatest  impoi-tance. 

Blood. — ^Haematuria  is  an  evidence  of  bleeding  from  some  part 
of  the  genito-urinar}^  tract.  So  far  as  the  kidneys  are  concerned 
the  blood  comes  from  their  pelves,  or  from  the  kidneys  them- 
selves. Bleeding  from  the  pelves  occurs  with  pyelitis,  with  cal- 
culi in  the  pelvis,  and  with  new  growths  of  the  pelvis.  Bleeding 
from  the  kidney  itself  is  found  with  acute  nephritis,  with  exacer- 
bations of  chronic  nephritis,  with  tubercular  nephritis,  with  the 
hemorrhagic  forms  of  the  infectious  diseases,  and  with  malignant 
growths. 

Hcemoglobinuria. — There  are  morbid  conditions  in  which  a 
considerable  number  of  red  blood-cells  are  suddenly  killed  and 
the  coloring  matter  set  free  in  the  blood.  This  is  followed  by  a 
discharge  of  this  coloring  matter,  with  a  considerable  transuda- 
tion of  blood  serum  from  the  kidneys,  in  the  urine.  We  find 
then  a  good  deal  of  albumin  and  of  red  coloring  matter  in  the 
urine,  but  no  red  blood-cells. 

Casts. — There  has  been  some  difference  of  opinion  as  to  the 
mode  of  formation  of  the  little  cylindrical  bodies  which  are  found 
in  the  urine  and  in  the  kidney  tubules.  The  question  has  been 
whether  they  are  all  formed  of  substances  coagulated  from  the 
blood  plasma,  or  whether  some  are  formed  of  substances  de- 
rived from  the  renal  epithelium.  Certainly  most  of  them  are 
formed  from  the  blood  plasma.  Tliey  are  composed  of  a  trans- 
parent, homogeneous  matter  with  which  may  be  mixed  renal 
epithelium,  white  and  red  blood-cells,  and  the  granular  matter, 
fat,  and  nuclei  derived  from  degenerated  epithelium.  The  pres- 
ence of  casts  in  the  urine   means,   therefore,  that  there   has   been 


THE    URINE.  271 

an  exudation  of  blood  serum  into  the  kidney  tubules  and  more 
or  less  degeneration  of  the  renal  epithelium.  The  number  of 
casts  in  the  urine  is  usually  an  indication  of  the  number  formed 
in  the  kidneys,  but  not  always  ;  we  may  find  but  few  casts  in  the 
urine  during  life,  and  yet  after  death  the  kidneys  are  seen  to 
contain  a  large  number.  Albumin  and  casts  are  usually  present 
in  proportionate  quantities  :  if  there  is  much  albumin  there  are 
generally  many  casts,  but  albumin  may  be  present  in  large  quan- 
tities with  very  few  casts.  The  centrifugal  machines  which  are 
now  in  use  are  of  great  assistance  in  looking  for  casts. 

Anyone  who  wishes  to  understand  casts  and  their  mode  of 
formation  must  look  at  them  in  kidney  sections,  as  well  as  in  the 
urine.  It  seems  hardly  necessary  to  warn  against  confounding 
cylindrical  strings  of  mucus  formed  in  the  bladder,  often  having 
crystals  imbedded  in  them,  with  casts  formed  in  the  kidney 
tubules,  but  the  mistake  is  sometimes  made. 

Hyaline  casts  in  small  numbers,  like  albumin  in  small  quan- 
tities, are  occasionally  present  without  disease  of  the  kid- 
neys. 

Acute  congestion  of  the  kidneys  often  gives  hyaline  casts, 
sometimes  granular  and  nucleate  casts. 

Chronic  congestion  gives  a  few  hyaline  casts. 

Acute  degeneration  gives  casts  according  to  its  severity — hya- 
line casts  only,  or  granular  and  nucleated  casts,  or  epithelial  and 
blood  casts. 

Chronic  degeneration  gives  only  a  few  hyaline  casts,  or  none 
at  all. 

Acute  exudative  and  acute  diffuse  nephritis  give  many  casts 
of  every  kind. 

Chronic  nephritis  with  exudation  gives  many  casts  of  all 
kinds,  their  number  much  increased  when  there  is  an  exacerba- 
tion of  the  nephritis. 

Chronic  nephritis  without  exudation  gives  a  few  hyaline  casts 
or  none  at  all. 

Dropsy. 

The  association  of  dropsy  with  kidney  disease  is  of  such  fre- 
quent occurrence  that  it  is  often  difficult  to  convince  both 
patients  and  physicians  that  "  Bright's  disease"  can  exist  when 
dropsy  is  absent. 


272  THE    URINE. 

If  we  go  through  the  list  of  diseases  of  the  kidney  we  find 
that  their  association  with  dropsy  is  as  follows  : 

Acute  congestion  of  the  kidney — no  dropsy. 

Chronic  congestion  of  the  kidney — dropsy  according  to  the  condi- 
tion of  the  heart. 

Acute  and  chi'onic  degeneration  of  the  kidney — no  dropsy. 

Acute  exudative  nephritis — subcutaneous  dropsy,  most  frequent 
with  nephritis  caused  by  scarlet  fever,  or  by  exposure  to  cold. 
A  similar  subcutaneous  oedema  can  be  produced  by  scarlet  fever 
or  by  exposure  to  cold  without  nephritis. 

Acute  productive  (or  diffuse)  nephritis — both  subcutaneous  dropsy 
and  dropsy  of  the  serous  cavities. 

Chronic  nephritis  with  exudation — dropsy  of  the  subcutaneous 
connective  tissue  and  of  the  serous  cavities  in  nearly  every  case. 

Chronic  nephritis  unthout  exudation — no  dropsy  until  late  in  the 
disease  unless  from  complicating  lesions. 

Suppression  of  urine  from  obstruction  of  the  ureters — no 
dropsy. 

The  primitive  explanation  of  renal  dropsy  was  that  fluids  ac- 
cumulated in  the  body  because  the  patient  passed  too  little 
water.  This  seemed  satisfactory  even  to  so  good  an  observer  as 
Bartels.  It  has  always  had  its  effect  on  therapeutics  ;  the  rule 
has  been,  if  a  patient  has  dropsy  make  him  pass  more  urine. 
This  explanation,  however,  is  in  constant  contradiction  with 
clinical  experience. 

The  present  condition  of  our  knowledge  on  this  subject  may 
be  stated  somewhat  as  follows  : 

1.  All  dropsies  are  due  to  an  increased  transudation  of  blood 
serum  from  the  capillaries  and  a  diminished  absorption  by  the 
lymphatics.  The  increased  transudation  is  the  more  important 
part  of  the  process. 

2.  Inflammatory  dropsies  (or  exudations)  and  passive  dropsies 
may  be  produced  in  one  of  two  ways  : 

{a)  The  capillaries  act  as  filters.  Either  increased  pressure,  a 
change  in  tlie  composition  of  the  serimi,  or  a  change  in  the  walls 
of  the  capillaries  can  cause  an  increased  transudation  through 
the  walls  of  the  capillaries. 

{p)  The  capillaries  with  their  endothelium  act  as  glands  and 
secrete  serum.  Changes  in  the  composition  of  the  blood  or 
irritating  substances  in  the  surrounding  tissues  can  irritate  the 
endothelium  and  cause  increased  secretion. 


THE    URINE.  273 

Following  these  rules,  the  probable  explanations  of  renal 
dropsies  are  : 

1.  In  acute  exudative  nephritis  tlie  dropsy  is  due  to  inflamma- 
tory changes  in  the  skin.  The  dropsy  is  regularly  confined  to 
the  subcutanefHis  connective  tissue,  and  is  especially  frequent 
when  the  nephritis  is  caused  by  scarlet  fever,  or  by  exposure  to 
cold. 

2.  In  acute  productive  nephritis  and  in  chronic  nephritis  with 
exudation  the  dropsy  involves  both  the  subcutaneous  connective 
tissue  and  the  serous  cavities.  It  may  be  due  to  irritating  sub- 
stances in  the  blood,  to  changes  in  the  composition  of  the  blood, 
or  to  changes  in  blood-pressure. 

3.  In  chronic  nephritis  without  exudation,  the  dropsy  which 
comes  on  late  in  the  disease  is  caused  by  changes  in  blood-pressure 
due  to  heart  failure. 

Scattered  through  medical  literature  are  reports  of  cases  of 
general  subcutaneous  dropsy  coming  on  suddenly,  lasting  for  a 
short  time,  without  any  evidence  of  renal  or  other  disease,  and 
terminating  in  recovery.  Traube  thinks  that  such  dropsies  are 
due  to  a  disturbance  of  the  functions  of  the  skin  caused  by  ex- 
posure to  the  weather,  but  this  explanation  will  not  answer  for  all 
the  cases,  in  some  patients  (Taylor,  Medical  Times  and  Gazette, 
187 1)  the  dropsy  Avas  preceded  by  a  well-marked  febrile  move- 
ment. I  onlv  know  of  one  case  of  this  kind  which  terminated 
fatally.  It  is  reported  by  Wernicke  [Dentsch.  Archiv  for  kliuische 
Medicin,  VI.,  622).  The  patient,  a  woman  twenty-two  years  old, 
died  apparently  from  the  dropsy,  and  the  autopsy  showed  no 
lesion  to  account  for  the  symptoms.  The  following  case  is  an 
example  of  this  form  of  dropsy  : 

Male,  26,  admitted  to  the  Roosevelt  Hospital  on  April  17, 
1884.  He  had  been  perfectly  well  and  working  hard  two  months 
ago.  Then  he  began  to  have  cough,  mucous  sputa,  and  wheez- 
ing breathing.  One  month  ago  he  developed  general  subcutane- 
ous oedema  ;  the  urine  was  somewhat  diminished  in  quantity, 
but  the  man  did  not  feel  sick.  When  admitted  to  the  hospital 
his  pulse  was  96,  temperature  98°  F.,  respiration  30.  There  was 
very  marked  general  subcutaneous  oedema.  The  skin  and 
mucous  membranes  were  rather  pale,  but  the  man  was  well- 
nourished  and  did  not  feel  at  all  sick.  A  soft  systolic  murmur 
could  be  heard  at  the  apex  and  base  of  the  heart  ;  the  action  of 
the  heart  was  somewhat  intermittent  and  irregular.     The  dropsy 


274 


THE   URINE. 


increased  for  a  few  days  and  then  gradually    diminished. 
record  of  the  urine  was  as  follows  : 


The 


Quantity  in 
Ounces. 


April 


19. 
20. 
21. 
22. 

23- 

24. 
25. 
26. 
27. 
28. 
29. 


42 
96 

130 

84 

132 

136 

62 

44 
45 


None 
Trace 


None 


Trace 
None 


Specific 
Gravity. 


1024 
IOI2 
1022 
lOIO 
1026 
1008 
IOI4 
IOI2 
1014 
IO16 
IOI4 
IOI6 


Urea  in 
grains. 


608 

340 

351 
280 

479 
672 

858 
410 
394 


By  May  ist  the  dropsy  had  entirely  disappeared  and  the  man 
was  apparenth'  well. 

I  have  seen  a  number  of  hospital  patients  who  unquestion- 
ably had  kidney  disease,  but  who  had  attacks  of  subcutaneous 
.oedema  after  exposure,  apparently  not  connected  witli  their  kid- 
ney disease,  but  caused  by  inflammation  of  the  skin. 

The  ordinary  treatment  of  dropsy  is  directed  to  the  removal 
of  the  serum  after  it  has  transuded  from  the  vessels.  We  try  to 
get  rid  of  the  dropsy  by  sweating,  by  diuresis,  or  by  purging.  It 
is  evident  that  a  much  more  satisfactory  treatment  would  be  to 
prevent  the  transudation.  If  we  could  find  remedies  to  destroy 
the  irritating  substances  in  the  blood  and  tissues  which  cause  the 
blood  serum  to  transude,  we  would  be  able  to  prevent  the  dropsy 
instead  of  havino:  to  get  rid  of  it. 


Albuminuria. 

Since  the  time  of  Richard  Bright  the  presence  of  albumin  in 
the  urine  has  been  regarded  as  a  proof  of  kidney  disease  both  by 
physicians  and  by  the  laity.  And  in  spite  of  all  evidence  to  the 
contrary  this  is  still  the  popular  belief.  It  is  true  tliat  any  edu- 
cated physician  will  now  admit  that  albumin  may  be  absent  with 
kidney  disease  and  present  without  it,  but  this  admission  is 
largely  theoretical.  In  practice  tlie  old  belief  makes  itself  felt, 
and  the  presence  of  albumin  is  still  looked  for  as  the  main  evi- 
dence of  disease  of  the  kidneys. 


THE    URINE.  275 

The  general  belief  concerning-  the  albumin  has  been  that  it  is 
removed  from  the  blood  by  the  kidneys  just  as  urea  or  sugar  is, 
and  that  if  large  quantities  of  it  are  removed  from  the  blood  the 
composition  of  this  fluid  is  changed.  A  good  deal  of  pains  has 
been  taken  to  discover  why  it  is  that  diseased  kidneys  should  ex- 
crete albumin. 

As  a  matter  of  fact,  the  presence  of  serum  albumin  and  serum 
globulin  in  the  urine  means  that  the  blood  serum,  of  which  they 
are  constituents,  has  become  mixed  with  the  urine.  The  simplest 
way  in  which  this  can  happen  is  to  have  bleeding  from  the  blad- 
der or  kidneys  so  that  the  blood  and  urine  are  mixed.  The  ordi- 
nary w\ay  is  for  the  blood  serum  to  transude  from  the  kidney 
capillaries  just  as  it  does  from  capillaries  in  other  parts  of  the 
body.  Album  n  in  the  urine,  therefore,  means  the  same  thing  as 
serum  in  a  serous  cavity,  that  there  has  been  a  transudation  of 
serum  from  tlie  vessels.  To  keep  the  matter  clear  in  our  minds, 
whenever  we  use  the  word  albuminuria  we  should  do  so  with  the 
idea  that  it  is  a  popular  way  of  saying  that  the  urine  has  blood 
serum  mixed  with  it.  In  this  way  we  will  think  of  the  kidney 
as  we  do  of  other  parts  of  the  body — as'  liable  to  exudations  of 
serum  either  of  inflammatory  or  of  dropsical  character.  But, 
just  as  in  the  serous  membranes  the  exudation  is  not  in  the  mem- 
brane but  in  its  cavity,  so  in  the  kidney  the  exudation  is  not  into 
the  parenchyma  but  into  the  tubules. 

The  causes  of  albuminuria,  therefore,  are  the  same  as  the 
causes  of  dropsies  in  all  parts  of  the  body  : 

1.  Changes  produced  by  infiainmation  in  the  walls  of  the  capillaries 
which  render  them  more  permeable.  In  this  Avay  are  produced 
the  albuminuria  of  both  forms  of  acute  nephritis,  of  the  severe 
forms  of  acute  degeneration,  of  acute  congestion,  and  of  some  of 
the  cases  of  chronic  nephritis  with  exudation. 

2.  Changes  in  the  composition  of  the  blood,  causing  either  in- 
creased filtration  or  increased  secretion  of  serum.  This  would 
account  for  the  albuminuria  of  anaemia,  of  puerperal  eclampsia 
without  nephritis,  of  the  mild  cases  of  acute  degeneration,  of 
some  of  the  cases  of  acute  and  chronic  nephritis  witli  exudation. 

3.  Changes  in  the  bloodpressure.  This  would  be  the  probable 
cause  of  the  albuminuria  in  some  of  the  puerperal  cases,  in 
chronic  congestion,  in  some  of  the  cases  of  chronic  nephritis  with 
exudation,  and  in  chronic  nephritis  without  exudation. 

4.  Non-inflainviatory  cliauges  in  the  ivalls  of  the  capillaries,  ren- 


276  THE    URINE. 

dering  them  more  permeable  to  the  escape  of  serum.  Such 
changes  would  account  for  the  albuminuria  which  is  found  with- 
out inflammation  of  the  kidneys,  changes  in  the  blood,  or  altera- 
tions in  the  blood-pressure. 

The  significance  of  albumin  in  the  urine  depends,  therefore, 
altogether  upon  its  causation.  As  a  symptom  it  may  be  com- 
pared to  cough.  It  is  well  known  that,  while  cough  is  a  frequent 
symptom  of  disease  of  the  lungs,  yet  its  presence  does  not  tell  us 
what  the  disease  of  the  lungs  is,  nor  does  it  even  tell  us  that 
there  is  necessarily  disease  of  the  lungs  at  all.  Albuminuria, 
while  it  always  means  that  the  capillaries  of  the  kidneys  allow 
the  blood  serum  to  transude  through  their  walls,  does  not  tell  us 
whether  the  causation  of  this  transudation  resides  in  the  kidneys 
or  outside  of  them.  The  study  of  this  causation  is  practically  a 
study  of  the  causes  of  dropsy. 

Albuminuria  without  Disease  of  the  Kidney. 

The  examination  of  the  urine  by  the  physicians  of  life  in- 
surance companies,  and  by  other  physicians  who  have  examined 
this  excretion  in  cases  of  school  children,  of  soldiers,  and  of  other 
groups  of  persons,  has  brought  out  the  fact  that  albumin  is 
present  in  the  urine  in  many  persons  who  have  no  disease  of 
the  kidneys.  These  persons  can  be  arranged  in  the  following 
groups  : 

I.  Paroxysmal  or  Cyclic  Albuminuria. — The  characteristic  feat- 
ures of  this  form  of  albuminuria  are  :  that  the  quantity  of  al- 
bumin is  large,  while  casts  are  few  or  absent  ;  that  if  we  examine 
the  urine  at  regular  intervals  during  the  twenty-four  hours  there 
is  a  regular  rise  and  fall  in  the  quantity  of  albumin.  The  albumin 
begins  to  appear  soon  after  rising  in  the  morning,  increases 
through  the  day,  falls  after  going  to  bed,  disappears  at  night, 
and  reappears  again  the  next  morning.  This  regular  cycle  can 
be  disturbed  by  changing  the  hours  of  rest,  of  meals,  and  of 
exercise.  The  rule  is  tliat  the  appearance  of  the  albumin  is 
favored  by  exercise  and  by  eating,  while  rest  in  bed  causes  it  to 
disappear.  Tliere  seems  to  be  no  way  of  accounting  for  this 
form  of  albuminuria,  except  by  supposing  that  there  are  changes 
in  the  composition  of  the  blood,  or  in  the  walls  of  the  renal  capil- 
laries. 

The  persons  in  whom  this  form  of  albuminuria  is  present  are 


THE    URINE.  277 

regularly  young  males,  who  also  suffer  from  more  or  less  dis- 
turbance of  the  general  health.  The  patients  suffer  from  anaemia, 
lose  flesh  and  strength,  have  headaches,  neuralgic  pains,  bodily 
and  mental  languor,  hysteria,  and  disturbances  of  the  functions 
of  the  stomacli,  liver,  and  intestines.  But  there  is  a  great  dif- 
ference in  the  patients  as  to  how  far  these  additional  symptoms 
are  developed.  In  some  they  are  but  trifling,  in  others  they  are 
well  marked. 

To  distinguish  these  patients  from  those  who  have  a  true 
nephritis  is  by  no  means  easy  ;  the  diagnosis  may  remain  doubt- 
ful for  montlis,  and  even  then  it  is  difficult  not  to  make  mistakes. 

The  treatment  of  these  patients  consists  in  the  regulation  of 
the  diet  and  mode  of  life,  and  the  management  of  the  disturb- 
ances of  digestion  and  of  the  condition  of  the  blood.  The  diet 
should  be  liberal  and  varied,  but  all  indigestible  articles  of  food 
must  be  excluded.  Massage,  hot  and  cold  baths,  and  regulated 
exercise  are  to  be  systematically  carried  out.  A  climate  which 
admits  of  many  hours'  daily  exposure  to  the  open  air  and  sun- 
light is  to  be  preferred. 

All  disorders  of  digestion  are  to  be  remedied  as  far  as  possible. 

The  change  in  the  composition  of  the  blood  is  not  marked  ; 
neither  the  quantity  of  iiaemoglobin  nor  the  number  of  blood- 
cells  is  mucli  diminished  ;  iron  is  of  service  in  the  treatment  of 
the  affection,  but  does  not  act  as  a  specific. 

The  prognosis  as  regards  the  life  and  health  of  these  patients 
is  good,  but  it  may  be  very  hard  to  get  rid  of  the  albumin  al- 
together, 

2.  Dietetic  Albiuninuria. — This  occurs  both  in  children  and  in 
adults.  It  may  follow  the  ingestion  of  only  certain  kinds  of  food 
— cheese,  pastry,  and  eggs  ;  or  of  any  kind  of  food  ;  or  of  any 
food  which  is  not  properly  digested  ;  or  it  may  occur  when  ex- 
ercise follows  immediately  upon  the  ingestion  of  food.  The 
quantity  of  albumin  is  small  and  there  are  few  or  no  casts. 

If  this  form  of  albuminuria  is  temporary,  it  is  not  a  serious 
condition,  but  if  the  disposition  to  it  persists,  the  patients  are  to 
be  regarded  with  suspicion.  They  are  also  liable  to  temporary 
glycosuria  ;  they  may  have  well-marked  functional  disturbance  of 
the  liver  ;  they  may  have  the  gouty  disposition  ;  or  they  may 
have  cirrhosis  of  the  liver,  or  chronic  endarteritis. 

The  treatment  consists  in  regulating  the  diet  and  exercise  in 
the  same  v\?ay  as  in  persons  with  the  gouty  disposition  ;  in  reliev- 


2/8  THE    URINE. 

ing  constipation  ;  and  in  the  use  of  the  drugs  whicli  are  likely  to 
increase  the  production  of  bile. 

3.  Albuminuria  after  Exertion. — The  exertion  must  be  severe 
and  prolonged,  in  long  and  fatiguing  marches  by  soldiers  ;  pro- 
longed contests  in  walking  or  running  ;  violent  exercises  such  as 
boxing  or  wrestling.  The  quantity  of  albumin  may  be  consider- 
able and  numerous  casts  may  also  be  present.  It  seems  prob- 
able that  this  form  of  albuminuria  is  due  to  a  congestion  of  the 
kidneys  caused  by  the  exertion.  After  the  cessation  of  the  ex- 
ertion the  albumin  regularly  disappears  within  a  few  hours  or 
days.  But  a  repetition  of  such  temporary  congestions  of  the 
kidney  might  lead  to  the  development  of  a  true  nephritis. 

4.  Simple  Persistent  Albuminuria. — These  patients  may  for 
years  have  small  quantities  of  albumin  nearly  every  day,  but  not 
at  all  hours  in  the  day.  The  albumin  is  not  abundant,  it  often 
disappears  after  rest ;  there  may  also  be  a  few  hyaline  casts. 
The  patients  have  no  other  symptoms  of  kidney  disease,  even 
when  they  are  under  observation  for  years.  But  one  always 
feels  anxious  concerning  such  persons.  Sooner  or  later  they  are 
apt  to  develop  chronic  nephritis,  or  endocarditis,  or  endarteritis. 

Uremia. 

It  is  well  established  that  tlie  principal  function  of  the  kid- 
neys is  to  remove  from  the  body  a  quantity  of  excrementitious 
substances.  It  is  equally  well  established  that  a  number  of  the 
diseases  of  the  kidney  interfere  witli  this  function  and  allow  the 
excrementitious  substances  to  accumulate  in  the  blood  and  tis- 
sues. It  is  a  matter  of  daily  observation  that  persons  who  suffer 
from  kidney  disease  exhibit  symptoms  of  such  a  character  as  to 
give  the  idea  that  these  persons  are  in  some  way  poisoned.  The 
sequence  seems  to  be  logical :  disease  of  the  kidneys,  failure  to 
eliminate  excrementitious  substances,  accumulation  of  such  sub- 
stances in  the  blood  and  tissues,  poisoning  of  the  body  by  these 
substances,  the  development  of  symptoms  due  to  the  poisoning. 
To  such  a  morbid  process  the  name  of  "  uraemia  "  can  properly 
be  given.  So,  in  the  year  1894,  we  find  the  following  definition 
of  uraemia  in  Dunglisnn's  Medical  Dictionary:  "  Certain  morbid 
phenomena,  implicating  the  nervous  centres  more  especially,  due 
to  retention  of  excrementitious  substances  in  the  blood  which  are 
normally  excreted  by  the  kidneys,  as  in  Bright's  disease."     And 


THE    URINE.  279 

this  definition  fairly  represents  the  popular  belief  concerning 
uraemia. 

Unfortunately  it  is  not  possible  to  dismiss  tlie  subject  in  this 
easy  way.  We  are  confronted  with  many  contradictions  difficult 
of  explanation,  and  a  review  of  the  history  of  the  subject  shows 
that  these  difficulties  have  always  been  felt. 

The  simplest  explanation  of  the  phenomena  of  uraemia — that 
they  are  due  to  the  presence  of  urea  in  the  blood — has  been  con- 
tended for  by  many  observers  from  the  time  of  Christison  down 
to  the  present  moment.  The  proof  has  been  derived  from  the  ex- 
amination of  the  blood  in  liuman  beings,  and  from  experiments 
on  animals. 

It  has  been  demonstrated  over  and  over  again  that  the  blood 
of  persons  suffering  from  uraemic  attacks  may  contain  a  large  ex- 
cess of  urea,  that  their  serous  effusions  may  contain  large  quan- 
tities of  urea,  and  even  that  the  urea  may  appear  as  a  dry  powder 
on  the  surface  of  the  skin.  It  has  also  been  shown  that  in  a  num- 
ber of  cases  the  outbreak  of  uraemic  convulsions  is  preceded  by  a 
diminution  in  the  excretion  of  urine  and  of  urea. 

The  experiments  on  animals  have  consisted  in  injections  of 
urea  into  the  veins,  in  the  introduction  of  urea  into  the  stomach, 
and  in  abolishing  the  function  of  the  kidneys  by  ligating  the 
blood-vessels  or  the  ureters. 

The  introduction  of  urea  in  considerable  quantities  into  the 
veins  or  into  the  stomach  is  well  borne  by  animals,  provided  that 
the  kidneys  perform  their  functions.  The  urea  is  eliminated 
with  the  urine.  If,  on  the  other  hand,  after  the  injection  of  urea 
into  the  blood  the  animal  is  entirely  deprived  of  fluids,  or  the 
functions  of  the  kidney  are  arrested  by  operation,  then  vomiting, 
diarrhoea,  muscular  contractions,  and  death  regularly  follow. 

Ligature  of  the  blood-vessels  of  the  kidneys,  or  of  their  ureters, 
or  extirpation  of  the  kidneys  is  followed  by  an  accumulation  of 
urea  in  the  blood  and  tissues.  The  animals  have  vomiting  and 
diarrhoea,  become  stupid,  and  die. 

The  contradictions  to  this  theory  of  uraemia  were  soon  noted. 
Owen  Rees  was  one  of  the  first  to  call  attention  to  the  fact  that 
prolonged  anuria  is  not  necessarily  accompanied  with  renal  symp- 
toms. His  illustrative  case  was  a  patient  in  whom  one  kidney 
was  absent  ;  the  ureter  of  the  other  kidney  became  blocked  by  a 
calculus,  and  there  was  complete  suppression  of  urine.  The  quan- 
tity of  urea  in  the  blood  was  much  increased.     The  patient  died, 


28o  THE   URINE. 

but  there  were  no  uraemic  symptoms.  Cases  of  suppression  of 
urine  lasting  for  a  number  of  days  are  not  infrequent,  and  the 
ordinary  experience  has  been  that  it  is  precisely  in  these  cases 
that  ursemic  symptoms  are  absent,  although  death  regularly  fol- 
lows. 

More  than  this,  Bartels  and  others  have  found  that  the  blood 
drawn  immediately  after  a  uraemic  attack  may  contain  no  excess 
of  urea.  It  is  a  matter  of  ordinary  experience  that  uraemic  symp- 
toms may  come  on  in  persons  who  are  passing  a  normal  quantity 
of  urine  of  good  specific  gravity.  So  there  seems  to  be  no  escape 
from  the  facts  that  complete  suppression  of  urine  is  not  regu- 
larly followed  by  uraemic  symptoms,  and  that  uraemic  symptoms 
may  occur  without  an  excess  of  urea  in  the  blood,  or  a  diminu- 
tion in  the  excretion  of  normal  urine. 

So  far  as  the  experiments  on  animals  are  concerned,  they  seem 
merely  to  show  that  urea  in  the  blood  does  but  little  harm,  and 
that  abolition  of  the  functions  of  the  kidneys  causes  death. 

It  was  to  escape  from  some  of  these  difficulties  that  Frerichs 
proposed  the  explanation  that  the  cause  of  uraemic  symptoms 
was  poisoning  by  carbonate  of  ammonia.  He  taught  that  urea 
in  excess  in  the  blood  did  no  special  harm,  but  that  if  by  the 
action  of  some  ferment  the  urea  was  changed  into  carbonate  of 
ammonia,  then  symptoms  of  intoxication  would  regularly  follow. 
This  theory,  at  one  time  popular,  is  now  so  entirely  abandoned 
that  it  is  not  necessary  to  state  the  objections  to  it. 

A  modification  of  the  theory  of  intoxication  by  urea  is  that  of 
intoxication  by  urea  and  the  other  excrementitious  substances  of 
the  urine  together.  The  same  affirmative  and  negative  facts  are 
to  be  found  for  this  theory  as  for  that  of  poisoning  by  urea  alone. 
Normal  uncontaminated  urine  injected  into  the  veins  of  animals 
seems  to  do  little  harm  unless  the  kidneys  of  these  animals  are 
injured  by  operation.  If  the  kidneys  are  operated  on,  the  ani- 
inals  die. 

In  human  beings  there  are  the  patients  with  uraemic  symptoms 
and  an  excess  of  excrementitious  substances  in  their  blood  and 
tissues  ;  the  patients  with  uraemic  symptoms,  but  without  any  ex- 
cess of  excrementitious  substances  ;  and  the  patients  with  anuria, 
an  excess  of  excrementitious  substances,  and  no  uraemic  symp- 
toms. 

A  very  important  modification  of  the  chemical  aspect  of  the 
question  is  that  made  by  Oppler  and  others.     They  hold  that  it 


THE   URINE.  281 

is  an  error  to  think  that  urea  or  any  other  constituent  of  the 
urine  acts  as  a  blood  poison.  Rather  an  interference  with  the 
functions  of  the  Icidneysmust  lead  to  a  disturbance  of  the  regular 
chemical  changes  in  all  parts  of  the  body.  Such  an  interference 
is  followed  by  a  change  in  the  nutrition  of  the  tissues  which 
shows  itself  in  loss  of  weight,  in  anaemia,  and  in  disturbances  of 
the  functions  of  the  brain.  This  way  of  looking  at  the  subject  is 
certainly  a  very  rational  one. 

The  opposition  to  all  the  chemical  explanations  of  uraemia 
looks  to  changes  in  the  blood-pressure  as  the  exciting  cause  of 
uraemic  attacks.  The  most  complete  theory  of  this  kind  is  that 
of  Traube. 

This  theory  explains  the  occurrence  of  uraemic  attacks  as  fol- 
lows :  The  disease  of  the  kidneys  causes  thinning  of  the  blood 
serum,  hypertrophy  of  the  left  ventricle  of  the  heart,  and  an  ex- 
cess of  blood-pressure  in  the  arteries.  If  by  any  accidental  cir- 
cumstance the  blood-tension  is  suddenly  increased,  or  the  blood 
serum  still  further  thinned,  oedema  and  anaemia  of  the  brain  are 
produced.  The  form  of  the  uraemic  attack  will  vary  with  the  por- 
tion of  the  brain  which  is  rendered  anaemic  or  oedematous.  If 
the  cerebral  hemispheres  alone  are  involved  the  patient  simply 
becomes  comatose  ;  if  the  central  portions  of  the  brain  alone  are 
affected  there  will  be  convulsions  without  coma  ;  if  both  the 
hemispheres  and  the  central  portions  of  the  brain  are  anaemic 
and  oedematous,  both  convulsions  and  coma  are  developed. 

Traube  also  states  : 

That  he  never  saw  an  attack  of  uraemia  in  renal  disease  where 
the  left  ventricle  of  the  heart  was  not  hypertrophied,  and  where 
an  increase  of  tension  in  the  aortic  system  could  not  be  demon- 
strated. 

That  the  diluted  state  of  the  blood  serum  can  be  recognized  by 
the  pallor  of  the  skin  and  mucous  membranes  and  the  presence 
of  dropsical  effusions. 

That  in  every  instance  in  which  he  examined  the  brain  after 
death  he  could  confirm  the  existence  of  anaemia  and  oedema. 

That  the  presence  of  blood  effusion  within  the  cranial  cavity 
in  many  of  these  cases  confirms  the  suspicion  that  the  abnor- 
mally high  arterial  blood-pressure  to  which  these  effusions  owe 
their  origin  has  also  something  to  do  with  the  production  of  the 
oedema  which  is  present  at  the  same  time. 

Experiments  on  animals  have  also  shown  that  by  ligating  the 


282  THE   URINE. 

ui-eters,  then  the  jugular  vein  on  one  side,  and  then  injecting 
water  into  the  carotid  on  the  same  side,  general  convulsions  and 
coma  can  be  produced.  After  death  oedema  of  the  brain  without 
extravasation  of  blood  is  found. 

The  objections  to  Traube's  theory  are  obvious  :  In  patients 
who  exhibit  well-marked  cerebral  symptoms  the  specific  gravity 
of  the  blood  serum  is  not  always  lowered  ;  the  arterial  tension  is 
not  always  increased  ;  neither  anaemia  nor  oedema  of  the  brain 
can  always  be  demonstrated  after  death.  These  are  facts  which 
are  soon  ascertained  by  anyone  who  sees  much  of  kidney  dis- 
ease. 

The  marked  ursemic  symptoms  which  occur  at  the  close  of 
pregnancy,  and  are  known  under  the  name  of  puerperal  eclamp- 
sia, differ  from  ordinary  uraemic  attacks  in  that  they  may  occur 
without  marked  structural  changes  in  the  kidneys.  A  variety  of 
explanations  have  been  offered  as  to  their  causation. 

The  older  British  and  American  obstetricians  taught  that  puer- 
peral convulsions  were  caused  by  determination  of  blood  to  the 
head — cerebral  congestion.  Traube's  theory  of  altered  blood, 
increased  arterial  tension  with  anaemia  and  oedema  of  the  brain 
can  be  applied  to  the  puerperal  cases  of  uraemia  as  well  as  to 
those  associated  with  kidney  disease. 

A  retention  in  the  blood  of  some  toxic  agent,  with  conse- 
quent poisoning  of  the  blood  centres,  has  been  a  favorite  theory 
with  many.  The  toxic  material  has  been  thought  to  be  :  urea, 
carbonate  of  ammonia,  urea  with  kreatin  and  other  excremen- 
titious  substances,  or  ptomaines  produced  by  the  growth  of 
bacteria. 

The  convulsions  are  attributed  by  some  to  cerebro-spinal  dis- 
turbance from  peripheral  stimulation  quite  independently  of  the 
kidneys.  Others  believe  that  the  convulsions  are  due  to  blood 
poisoning,  but  that  the  renal  disturbance  which  causes  the  blood 
poisoning  is  due  to  vasomotor  spasm  of  the  small  renal  vessels 
with  consequent  degenerative  changes  in  the  kidneys,  the  vaso- 
motor spasm  resulting  from  some  reflex  irritation. 

It  is  also  believed  that  some  puerperal  convulsions  are  simply 
acute  epileptic  attacks,  the  area  of  distribution  of  the  sciatic  nerve 
being  the  epileptogenic  zone. 

More  recently  attention  has  been  called  to  the  probability 
that  the  so-called  uraemic  symptoms  are  due  to  a  poison  in  the 
blood,  but  that  this  poison  is  not  due  to  any  disturbance  of  the 


THE   URINE.  283 

function  of  the  kidneys.  This  idea  is  only  a  theory,  but  it  offers 
a  promising  field  for  study.  It  may  very  well  be  that  we  must 
look  for  the  cause  of  these  symptoms  altogether  outside  of  tiie 
kidneys. 

It  is  evident  from  what  has  been  said  that  there  is  no  entirely 
satisfactory  way  of  accounting  for  the  so-called  ursemic  symp- 
toms. At  the  present  time  the  only  very  useful  thing  to  do  is  to 
try  and  state  as  clearly  as  possible  the  conditions  of  the  problem 
which  we  wish  to  solve. 

The  symptoms  which  it  is  customary  to  call  uraemic  are  : 

I.  Headache  and  sleeplessness,  which  come  on  in  attacks  of 
short  duration,  or  may  be  continued  for  many  weeks.  The 
headache  may  be  of  mild  type  or  very  severe.  In  extreme 
cases  the  pain  is  so  severe  and  the  sleeplessness  so  distressing 
that  the  patients  are  almost  maniacal.  These  symptoms  may 
accompany  : 

{a)  Puerperal  Eclampsia  either  with  or  without  Nephritis. 
At  the  time  of  the  attack  the  urine  is  diminished  in  quantity  but 
of  good  specific  gravity.  The  arteries  are  full  and  tense,  the 
heart's  action  is  exaggerated,  the  veins  are  congested.  The 
headache  can  be  relieved  by  the  birth  of  the  child,  by  general 
blood-letting,  by  morphine,  and  by  the  drugs  which  dilate  the 
arteries. 

(^)  Acute  Exudative  and  Acute  Productive  Nephritis.  At 
the  time  of  the  attack  the  urine  is  often,  but  not  always,  dimin- 
ished ;  its  specific  gravity  is  good.  The  arteries  are  full  and 
tense,  the  heart's  action  is  exaggerated.  The  headache  can  be 
relieved  by  the  arterial  dilators,  by  morphine,  by  purging,  by 
sweating.     General  blood-letting  can  but  seldom  be  used. 

{c)  Chronic  Nephritis  with  Exudation.  The  urine  is  often 
diminished,  but  may  be  increased  in  quantity ,  its  specific  grav- 
ity is  low.  The  condition  of  the  arteries  and  heart  is  not  con- 
stant. The  arteries  may  be  full  and  tense,  or  small  and  tense, 
or  full  and  soft,  or  small  and  feeble.  The  heart's  action  may  be 
exaggerated  or  feeble  ;  the  valves  may  be  diseased,  or  the  left 
ventricle  hypertrophied.  The  headache  can  sometimes  be  re- 
lieved, but  late  in  the  disease  nothing  will  control  it.  The  ar- 
terial dilators  are  of  use  only  when  the  pulse  is  tense.  The  car- 
diac stimulants  may  do  good  when  the  heart's  action  is  feeble. 
Thorough  daily  sweating  is  sometimes  efficient.  Purging  can 
give  temporary  relief.     Opium  may  be  the  only  drug  that  is  of 


284  THE   URINE. 

any  use.     Mild   cases   can  be  relieved  by  improving  the   action 
of  the  digestive  tract. 

{d)  Chronic  Nephritis  without  Exudation.  The  headache 
and  sleeplessness  are  especially  frequent  and  severe  with  this 
form  of  nephritis.  The  urine  is  often  diminished,  but  may  be 
increased,  or  normal  in  quantity  ;  its  specific  gravity  is  low. 
The  condition  of  the  heart  and  arteries  is  liable  to  the  same 
variations  as  in  chronic  nephritis  with  exudation,  but  a  full, 
tense  pulse  and  an  hypertrophied  left  ventricle  are  more  regu- 
larly present.  The  first  attack  of  headache  can  usually  be  re- 
lieved, but  each  successive  attack  is  more  difficult  to  manage. 

2.  Hemiplegia  and  Aphasia. — These  two  symptoms,  which  may 
occur  separately  or  together,  are  seen  in  patients  who  have 
chronic  nephritis  without  exudation,  and  in  women  with  puer- 
peral eclampsia.  The  invasion  of  the  hemiplegia  is  sudden  and 
it  is  usually  accompanied  by  coma.  There  is  loss  of  motion 
alone,  or  of  both  motion  and  sensation.  The  hemiplegia,  coma, 
and  aphasia  may  continue  up  to  the  time  of  the  patient's  death, 
or  disappear  after  a  few  days.  In  the  latter  case  the  patient 
may  have  several  such  attacks.  In  chronic  nephritis  the  hemi- 
plegia may  occur  either  early  or  late  in  the  course  of  the  dis- 
ease. In  these  patients  chronic  endarteritis,  especially  of  the 
cerebral  arteries,  is  very  regularly  present.  I  think  that  it  is 
probable  that  the  hemiplegia  is  due  to  the  endarteritis,  rather 
than  to  the  kidney  disease. 

The  treatment  of  this  condition  is  not  satisfactory.  If  there 
is  well-marked  arterial  tension  it  may  be  proper  to  try  and  re- 
duce it,  otherwise  it  is  better  not  to  interfere. 

3.  Sudden  Blindness. — Besides  the  loss  of  vision  due  to  ne- 
phritic retinitis,  there  may  be  a  sudden  blindness  which  lasts  for 
hours  or  days.  In  these  patients  no  anatomical  changes  in  the 
eyes  have  been  discovered.  This  form  of  blindness  is  not  un- 
common in  puerperal  eclampsia  ;  it  occurs  in  a  moderate  num- 
ber of  the  cases  of  chronic  nephritis.  We  do  not  understand 
the  nature  or  treatment  of  this  blindness  ;  fortunately  it  only 
lasts  for  a  short  time. 

4.  General  Epileptiform  Conimlsions. — These  have  always  at- 
tracted much  attention  as  one  of  the  most  terrible  and  danger- 
ous of  the  results  of  kidney  disease.     They  may  accompany  : 

{a)  Puerperal  Eclampsia,  either  with  or  without  nephritis, 
coming  on  either  before,  during,  or  after  labor.     At  the  time  of 


THE   URINE.  285 

the  attack  the  urine  is  sometimes  diminished  or  suppressed, 
sometimes  of  normal  quantity.  The  arteries  are  regularly  full 
and  tense,  the  heart's  action  is  exaggerated,  the  skin  is  con- 
gested. It  seems  to  be  generally  conceded  that  in  these  pa- 
tients the  convulsions  are  not  all  due  to  the  same  cause.  There 
is  also  a  substantial  agreement  as  to  the  best  methods  of  treat- 
ment. General  blood-letting  for  the  patients  with  excessive 
venous  congestion,  chloroform  inhalations  for  the  irritable  pa- 
tients, and  the  drugs  which  dilate  the  arteries,  are  the  routine 
treatment. 

{b)  Both  Forms  of  Acute  Nephritis.  In  children  suffering 
from  acute  nephritis  convulsions  are  of  quite  frequent  occur- 
rence, even  when  the  disease  is  not  of  severe  type.  So  many 
children  recover  after  one  or  more  convulsions  that  they  are  not 
grave  symptoms.  In  adults  convulsions  do  not  occur  nearly  as 
often  as  in  children,  but  when  they  do  occur  the  patients  are 
much  more  likely  to  die.  In  children  general  blood-letting  can 
very  seldom  be  practised  ;  in  adults  there  are  a  few  cases  in 
which  it  is  appropriate.  In  most  of  the  patients  the  drugs  which 
dilate  the  arteries  give  altogether  the  best  results. 

{c)  Chronic  Nephritis  with  Exudation.  The  convulsions  be- 
long to  the  advanced  cases  of  the  disease,  to  the  patients  who  are 
dropsical,  anaemic,  and  apparently  thoroughly  poisoned  with  ex- 
crementitious  substances.  The  heart's  action  and  pulse  are  fee- 
ble. In  these  patients  it  is  difficult,  or  impossible,  to  control  the 
convulsions.  The  most  efficient  plan  seems  to  be  the  daily 
sweating  with  the  hot  pack. 

There  are  cases  of  chronic  nephritis  with  exudation  in  which 
an  exacerbation  of  the  inflammation  takes  place,  and  the  patients 
then  behave  much  as  if  they  had  an  acute  nephritis. 

{d)  Chronic  Nephritis  without  Exudation.  Convulsions  are 
of  frequent  occurrence  early  in  the  disease  as  well  as  late  ;  in- 
deed, in  many  persons  the  attack  of  convulsions  is  the  first  symp- 
tom of  the  nephritis.  Many  of  the  patients  have  hypertrophy  of 
the  left  ventricle  of  the  heart  and  chronic  endarteritis  in  addition 
to  the  nephritis.  Common  as  these  attacks  are,  their  causation 
is  most  obscure,  for  there  can  be  no  question  that  the  liability 
to  the  convulsions  is  not  at  all  in  proportion  to  the  failure  of  the 
functions  of  the  kidneys.  Certainly  a  marked  increase  in  ar- 
terial tension  is  the  rule  with  these  attacks,  and  the  control  of 
the  convulsions  is    in  proportion  to   the  success   in  dilating   the 


286  THE   URINE. 

arteries.  But  there  are  cases  in  which  we  are  not  able  either  to 
dilate  the  arteries  or  to  control  the  convulsions  ;  and  there  are 
cases  in  which  the  convulsions  continue  although  the  pulse  be- 
comes rapid  and  feeble.  It  is  for  the  convulsions  with  this  form 
of  nephritis  that  hypodermics  of  morphine  are  of  so  much  efficacy 
for  a  time.  It  must  be  admitted  that  when  a  patient  with  chronic 
nephritis  begins  to  have  convulsions  death  is  not  far  off. 

5.  Contractions  of  Groups  of  Muscles. — These  are  of  common 
occurrence  in  the  severe  forms  of  acute  and  chronic  nephritis 
and  in  puerperal  eclampsia.  Very  often  they  merely  precede  an 
attack  of  general  convulsions.  They  are  best  marked  and  of 
longest  continuance  in  the  advanced  cases  of  chronic  nephritis 
with  exudation. 

6.  Delirium  and  Coma. — They  come  on  suddenly  in  attacks, 
either  associated  with  convulsions  or  by  themselves  ;  or  they  are 
developed  slowly  and  gradually  and  continue  for  a  considerable 
length  of  time.  The  attacks  belong  to  the  severe  cases  of  acute 
nephritis,  to  the  exacerbations  of  chronic  nephritis  with  exuda- 
tion, and  to  the  ordinary  cases  of  chronic  nephritis  without  exu- 
dation. The  gradual  development  of  delirium  and  coma  is  apt 
to  continue,  although  sometimes  with  intervals  of  improvement, 
up  to  the  time  of  the  patient's  death.  They  are  very  often  seen 
in  the  advanced  stages  of  both  forms  of  chronic  nephritis. 

7.  Vomiting  is  seen  in  many  cases  of  nephritis.  It  is  evidently 
due  to  a  number  of  different  causes.  In  acute  nephritis  the  vomit- 
ing seems  to  be  of  the  same  character  as  that  which  may  occur 
with  an  acute  inflammation  of  any  part  of  the  body.  In  chronic 
nephritis  the  vomiting  may  be  due  to  chronic  gastritis  ;  or  the 
stomach,  like  the  intestine,  gets  rid  of  some  of  the  accumulated 
urea  and  serum. 

Besides  these  forms  of  vomiting  there  is  a  special  and  aggra- 
vated form  which  belongs  regularly  to  the  cases  of  chronic 
nephritis  without  exudation.  It  is  usually  accompanied  by  a 
marked  increase  of  arterial  tension.  The  vomiting  is  frequent, 
distressing,  and  may  continue  for  days.  The  most  efficient 
means  of  controlling  it  are  chloral  hydrate  by  the  rectum  in 
twenty-grain  doses,  or  hypodermic  injections  of  morphine. 

8.  A  Rise  of  Temperature. — In  acute  nephritis,  as  in  any  other 
acute  inflammation,  there  may  be  a  febrile  movement.  As  a  rule 
the  temperature  is  not  high,  and  falls  to  the  normal  within  a  week. 
But  in  children  temperatures  of  104°  or  105°  F.  may  be  reached. 


THE    URINE.  287 

In  chronic  nephritis  tlie  severe  attacks  of  cerebral  symptoms 
— headache,  convulsions,  delirium,  coma,  hemiplegia — are  not 
infrequently  accompanied  with  a  considerable  rise  of  tempera- 
ture. I  have  seen  it  as  high  as  109°  F.,  and  yet  the  autopsies 
show  no  reason  for  the  febrile  movement. 

9.  Dyspnxa  is  one  of  the  most  frequent  and  interesting  of  the 
symptoms  of  nephritis.  There  is  a  dyspnoea  due  to  fluid  in  the 
pleural  cavities,  or  to  oedema  of  the  lungs  ;  a  dyspnoea  due  to 
the  pressure  on  the  diaphragm  by  fluid  in  the  abdomen  ;  and  a 
dyspnoea  due  to  bronchitis  or  to  contraction  of  the  bronchi  ;  but 
the  most  important  form  of  dyspnoea  is  one  which  is  independent 
of  all  these  causes,  and  is  directly  caused  by  disturbances  of  the 
circulation.  It  belongs  to  both  forms  of  chronic  nephritis,  but 
is  more  common  with  nephritis  without  exudation.  The  patients, 
as  a  rule,  in  addition  to  the  nephritis  have  pulmonary  emphy- 
sema, chronic  endarteritis,  hypertrophy  of  the  left  ventricle,  or 
chronic  endocarditis.  Not  infrequently  one  or  more  of  these 
lesions  is  much  more  advanced  and  apparently  more  important 
than  the  kidney  disease.  Especially  is  this  the  case  with  chronic 
endarteritis,  which  gives  many  of  the  most  marked  examples  of 
this  form  of  dyspnoea  with  but  very  little  nephritis. 

The  dyspnoea  may  come  on  at  any  time  in  the  course  of  a  ne- 
phritis ;  verv  often  it  is  the  first  symptom  which  causes  the 
patient  to  seek  medical  advice.  It  begins  with  attacks  which  at 
first  are  brought  on  by  bodily  and  mental  exertion,  or  come  on 
of  themselves  at  an  early  hour  in  the  morning.  In  none  of  the 
attacks  do  we  hear  the  characteristic  breathing  of  bronchial 
asthma.  The  attacks  at  first  only  last  for  an  hour  or  so,  and  dur- 
ing the  rest  of  the  day  the  breathing  is  comfortable.  But  even 
in  these  mild  attacks  the  patients  cannot  lie  down.  As  time  goes 
on  the  attacks  become  more  frequent  and  of  longer  duration. 
Finally  comes  the  terrible  period  when  the  breathing  is  always 
bad,  the  patients  cannot  lie  down  at  all,  and  yet  go  on  living  for 
weeks  and  months. 

The  treatment  of  this  dyspnoea  is  often  for  a  time  extremely 
satisfactory.  The  patients  are  enabled  to  live  and  work  in  com- 
fort for  many  years.  But  each  succeeding  attack  is  harder  to 
control  than  the  first,  and  finally  there  comes  a  time  when  every- 
thing fails  and  the  dyspnoea  continues  although  the  patient  is 
stupefied  with  drugs. 

The  object  of  treatment  is  to  relieve  the  disturbances  of  the 


288  THE   URINE. 

circulation  ;  if  this  can  be  done  the  dyspnoea  is  also  relieved. 
To  effect  this  the  most  exact  study  of  the  circulation  is  required. 
For  each  patient  the  character  of  the  heart's  action  and  of  the 
pulse,  both  relatively  and  separately,  must  be  determined. 
Based  on  this  knowledge  is  the  intelligent  use  of  cardiac  stimu- 
lants and  sedatives,  of  arterial  dilators,  of  regulation  of  the  func- 
tions of  the  stomach,  liver,  and  intestines,  of  rest  or  exercise. 
There  is  no  one  plan  of  treatment  for  all,  nor  even  one  plan  for 
the  same  patient  in  all  attacks. 

Increased  Arterial  Tension. — This  is  not  alwavs  classed  with  the 
uraemic  symptoms.  It  is,  however,  one  of  the  most  frequent  and 
important  of  the  symptoms  of  chronic  nephritis  ;  and  it  is  by  it 
that  many  of  the  so-called  uraemic  symptoms  are  produced. 

It  has  been  believed  that  this  increased  tension  of  the  blood 
in  the  arteries  is  due  to  chronic  changes  in  the  walls  of  the  arte- 
ries and  capillaries  which  interfere  with  the  passage  of  the  blood 
through  them.  The  explanation  is  very  probably  true  up  to  a 
certain  point,  but  it  does  not  account  for  the  attacks  of  increased 
arterial  tension  which  come  and  go  within  a  few  hours.  I  do  not 
see  how  these  can  be  produced  except  by  the  temporary  con- 
traction of  arteries  which  have  a  well-developed  muscular  coat, 
such  as  the  radial  artery.  I  think  that  it  is  possible  to  demon- 
strate after  death  in  such  arteries  an  hypertrophy  of  the  muscu- 
lar coat,  in  patients  who  have  had  many  attacks  of  increased 
arterial  tension. 

If  this  is  admitted,  then  we  have  to  find  a  reason  for  the  at- 
tacks of  contraction  of  the  arteries  which  last  for  hours  or  for 
weeks,  and  which  can  often  be  controlled  by  the  drugs  which 
dilate  the  arteries. 

Such  attacks  of  contraction  of  the  arteries  occur  with : 

Attacks  of  angina  pectoris. 

Chronic  endocarditis. 

Chronic  arteritis. 

Pulmonary  emphysema. 

Chronic  nephritis. 

It  seems  as  if  such  a  contraction  of  the  arteries  must  be  due 
to  some  irritating  substance  in  the  blood.  But  whether  there  is 
only  one  poison  which  acts  in  this  way  or  several  poisons,  and 
how  such  poison  or  poisons  are  produced,  we  do  not  know. 


THE   URINE.  289 


Acute  Congestion  of  the  Kidneys. 

definition. 

A  temporary  congestion  of  the  blood-vessels  of  the  kidney, 
which  may  be  accompanied  with  exudation  of  serum  and  escape 
of  red  blood-cells. 

ETIOLOGY. 

Acute  congestion  is  caused  by  the  ingestion  of  certain  poi- 
sons, by  extirpation  of  one  of  the  kindneys,  by  severe  injuries 
inflicted  on  any  part  of  the  body,  by  surgical  operations,  espe- 
cially those  on  the  bladder  and  urethra,  and  by  over-exertion. 

MORBID    ANATOMY. 

It  is  but  seldom  that  we  are  able  to  obtain  human  kidneys  in 
the  state  of  acute  congestion,  for  the  condition  is  not  usually  a 
fatal  one.  In  animals,  however,  the  condition  can  be  produced 
experimentally  by  cantharidin.  It  is  found  that  the  kidneys  are 
enlarged,  that  the  veins,  capillaries,  and  Malpighian  tufts  contain 
an  increased  qixantity  of  blood,  and  that  the  epithelial  cells  of  the 
cortex  tubes  are  flattened. 

SYMPTOMS. 

Acute  congestion  may  occur  in  kidneys  previously  normal,  or 
in  those  already  diseased. 

The  urine  is  diminished  in  quantity  or  suppressed  ;  its  specific 
gravity  is  unchanged  ;  it  contains  blood,  albumin,  and  casts. 

(i)   Congestion  Caused  by  the  Ingestion  of  Poisons. 

Cantharides  given  internally,  or  used  in  blisters  or  ointment, 
is  rather  a  frequent  cause  of  acute  congestion  of  both  the  kidneys 
and  the  bladder. 

The  urine  is  diminished  in  quantity;  it  is  passed  frequently, 
in  small  quantities,  with  much  pain  ;  or  it  is  retained.  It  con- 
tains albumin,  a  few  casts,  and  blood.  Sometimes  large,  jelly- 
like coagula  are  formed  in  the  bladder. 


290  THE   URINE. 

The  patients  may  have  a  moderate  rise  of  temperature,  pain 
in  the  back,  abdominal  pain,  nausea,  and  vomiting,  diarrhoea, 
more  or  less  prostration,  delirium,  and  stupor.  The  severity  of 
the  symptoms  depends  on  the  quantity  of  the  drug  absorbed.  In 
the  bad  cases  of  poisoning  the  condition  of  the  kidneys  is  not 
that  of  hyperaemia,  but  of  actual  inflammation. 

When  there  is  only  hypersemia  the  patients  are  sick  for  a  few 
days,  and  the  urine  soon  returns  to  its  natural  condition.  Tur- 
pentine produces  symptoms  like  those  of  cantharides. 

Treatment. — If  the  poison  has  been  taken  into  the  stomach, 
that  organ  is  to  be  emptied  and  washed  out.  Warm  baths,  or  a 
hot  pack,  and  the  use  of  small  doses  of  opium  are  of  service. 
Camphor  in  doses  of  from  2  to  5  grains  every  three  hours  has 
been  recommended  in  cantharides  poisoning. 

(2)   Congestion  folloimng  the  Removal  of  One  Kidney. 

The  urine  is  scanty  or  suppressed,  and  contains  albumin  and 
casts.  The  patients  are  in  a  condition  of  prostration  which  is 
very  alarming.  They  may  remain  in  this  condition  for  a  few 
days  and  then  recover,  the  urine  returning  after  a  time  to  its 
natural  condition  ;  or  they  become  more  and  more  feeble,  pass 
into  the  typhoid  condition  with  mild  delirium,  and  die. 

Treatment. — The  patients  are  to  be  kept  perfectly  quiet  in  bed, 
on  a  fluid  diet.  They  should  have  one  or  two  long  hot  packs 
every  day,  so  as  to  produce  congestion  of  the  skin  and  profuse 
perspiration. 

(3)   Congestion  of  the  Kidneys  after  Injuries  or  Surgical  Operatio7is. 

It  is  well  known  that  any  operation  on  the  bladder  or  urethra, 
even  the  passage  of  a  catheter,  may  be  followed  by  suppression 
of  urine,  great  prostration,  and  death  within  forty-eight  hours, 
and  that  after  death  no  lesion  is  found  except  congestion  of  the 
kidneys.  These  cases  are  not  to  be  confounded  with  the  cases  of 
septic  infection  and  fever,  which  may  also  follow  operations  on 
the  urethra  and  bladder. 

It  is  not  so  well  known  that  surgical  operations  on  any  part 
of  the  body  are  occasionally  followed  by  suppression  of  urine, 
congestion  of  the  kidneys,  and  death.  We  do  not  know  that 
death  in  all  these  cases  is  caused  by  the  congestion  of  the  kid- 


THE    URINE.  291 

neys,  but  there  can  be  no  question  that  congestion  of  the  kidneys 
is  produced  in  this  way. 

Treatment. — No  satisfactory  treatment  has  yet  been  found  for 
these  patients  ;  in  fact,  the  very  short  time  which  intervenes  be- 
tween the  operation  and  death  hardly  gives  time  for  treatment. 


(4)  Acute  Congestion  after  Over-exertion. 

Prolonged  marches,  violent  gymnastic  exercises,  contests  of 
walking  and  running  prolonged  over  several  days,  may  be  fol- 
lowed by  the  excretion  of  such  a  quantity  of  albumin  and  casts 
in  the  urine  as  to  indicate  a  temporary  congestion.  I  do  not 
know  of  any  post-mortem  observations  which  corroborate  this 
belief.  Tliere  are  no  other  symptoms  besides  the  changes  in  the 
urine,  and  these  disappear  after  a  few  days'  rest. 


Chronic  Congestion  of  the  Kidneys. 

There  are  a  number  of  morbid  conditions  which  interfere  with 
the  circulation  of  the  blood  in  the  aortic  system  in  such  a  way 
that  the  blood  accumulates  in  the  veins  and  is  diminished  in  the 
arteries.  The  most  common  of  these  conditions  are  :  chronic  in- 
flammation of  the  aortic  and  mitral  valves,  dilatation  of  the  heart, 
aneurism  of  the  arch  of  the  aorta,  pulmonary  emphysema,  and 
large  accumulations  of  fluid  in  the  pleural  cavities. 

In  pulmonary  emphysema  the  disturbances  of  circulation  are 
confined  to  the  cases  in  which  there  is  obstruction  to  the  passage 
of  blood  through  the  lungs,  dilatation  and  hypertrophy  of  the 
right  ventricle,  and  then  venous  congestion  of  the  aortic  system. 
More  or  less  dropsy  is  regularly  developed  at  about  the  same 
time  as  the  congestion  of  the  kidneys. 

Large  accumulations  of  fluid  in  the  pleural  cavities,  if  they 
remain  for  any  length  of  time,  may  produce  well-marked  chronic 
congestion.  This  is  denied  by  Bartels,  who  says  that  he  has 
never  known  congestion  or  any  serious  disturbance  of  the  renal 
functions  to  occur  as  a  result  of  pleuritic  exudations.  I  have, 
however,  seen  congestion  produced  in  this  way  a  number  of 
times.  I  think  that  it  is  a  lesion  of  consequence  to  the  patient, 
and  I  believe  that  it  furnishes  an  additional  reason  for  the  early 
removal  of  fluid  from  the  pleural  cavities. 


292  THE    URINE. 


ETIOLOGY. 

By  far  the  most  common  cause  of  chronic  congestion  of  the 
kidneys  is  disease  of  the  heart.  So  long  as  a  heart  with  chronic 
endocarditis,  or  myocarditis,  or  dilatation,  is  able,  in  spite  of  its 
damaged  state,  to  carry  on  the  circulation  fairly  well,  no  second- 
ary changes  in  the  kidneys  are  produced.  But  as  soon  as  the 
blood  accumulates  in  the  veins  to  any  considerable  extent  the 
kidneys  suffer.  One  of  three  things  regularly  happens  to  them  : 
either  chronic  congestion,  or  chronic  degeneration,  or  chronic 
nephritis  is  developed.  It  is  also  necessary  to  remember  that 
chronic  endocarditis  and  chronic  nephritis  often  exist  in  the  same 
person,  although  neither  one  of  them  is  secondary  to  the  other. 

MORBID    ANATOMY. 

The  kidneys  are  of  medium  size,  or  rather  large.  Their 
weight  is  increased,  somewhat  out  of  proportion  to  the  increase 
in  size.  The  color  is  dark-red,  the  consistence  is  very  hard,  the 
surfaces  are  smooth,  the  capsules  are  not  adherent.  The  conges- 
tion is  most  marked  in  the  veins  of  the  pyramids  ;  they  contain 
an  increased  quantity  of  blood,  and  are  often  dilated.  The  capil- 
laries of  the  cortex  are  also  congested,  but  it  is  rather  excep- 
tional to  find  them  dilated.  The  epithelium  of  the  convoluted 
tubes  is  swollen,  and  the  separate  cells  or  which  it  is  composed 
are  more  evident.  Or,  instead  of  this,  the  epithelium  is  much 
flattened,  so  that  the  lumen  of  the  tube  is  larger.  I  think  that 
this  flattening,  of  the  epithelium  belongs  to  the  kidneys  which 
give  urine  containing  a  good  deal  of  albumin. 

The  most  constant  and  characteristic  change  is  in  the  glo- 
meruli. The  capillaries  which  make  up  the  glomerulus  are  di- 
lated, with  more  or  less  thickening  of  their  walls.  So  far  as  I 
know  this  change  in  the  glomeruli  is  constant  and  persists,  even 
if  the  congestion  is  succeeded  by  a  true  nephritis. 

While  the  congestion  often  persists  up  to  the  time  of  the  pa- 
tient's death,  it  may,  instead  of  this,  be  followed  by  an  acute  or 
a  chronic  nephritis. 

If  there  is  an  acute  nephritis  albumin  is  present  in  considera- 
ble quantities  in  the  urine.  After  death  the  glomeruli,  in  addi- 
tion  to  the  dilatation  of  their  capillaries,  show  an  increase  in  the 


THE   URINE.  293 

size  and  number  of  the  cells  which  cover  them.     The  epithelium 
of  the  convoluted  tubes  is  flattened. 

If  there  is  a  chronic  nephritis  the  specific  gravity  of  the  urine 
falls  and  the  excretion  of  urea  is  diminished.  The  nephritis  fol- 
lows the  anatomical  type  of  a  chronic  nephritis  without  exuda- 
tion, but  the  dilatation  of  the  capillaries  of  the  glomeruli  persist. 

SYMPTOMS. 

Of  the  persons  who  die  with  chronic  congestion  of  the  kid- 
neys a  large  number  present  marked  symptoms  during  life,  but 
it  is  difficult  to  determine  how  largely  these  symptoms  are  due 
to  the  congestion  of  the  kidneys. 

A  congestion  of  a  few  weeks'  duration,  such  as  we  see  with 
large  effusions  of  fluid  in  the  pleural  cavities,  seems  to  give  no 
renal  symptoms  and  no  changes  in  the  urine. 

The  question  is  complicated  by  the  fact  that,  with  chronic 
endocarditis  and  pulmonary  emphysema,  any  one  of  the  follow- 
ing kidney  lesions  may  coexist  : 

1.  Chronic  congestion. 

2.  Chronic  congestion  followed  by  chronic  exudative  ne- 
phritis. 

3.  Chronic  congestion  followed  by  chronic  nephritis  without 
exudation. 

4.  Chronic  degeneration. 

5.  Chronic  degeneration  followed  by  chronic  nephritis  with 
exudation. 

6.  Chronic  nephritis  with  exudation  not  preceded  by  conges- 
tion. 

7.  Chronic  nephritis  without  exudation  not  preceded  by  con- 
gestion. 

Here  are  seven  different  kidney  lesions,  each  one  of  them  fre- 
quently associated  with  cardiac  disease. 

In  bad  cases  of  heart  disease  the  ordinary  symptoms  are  : 
dyspnoea,-  cough  and  expectoration,  general  dropsy,  vomiting, 
headache,  delirium,  convulsions,  coma,  anaemia,  loss  of  flesh  and 
strength. 

It  is  always  difficult,  and  often  impossible,  in  any  given  case  of 
heart  disease  to  determine  certainly  which  kidney  lesion  exists. 
The  general  rules  which  we  follow  are  these  : 

Chronic    Congestion. — The   cardiac    symptoms    not   as   severe  ; 


294  THE   URINE. 

dropsy  often  present  ;  the  quantity  of  the  urine  moderately  di- 
minished, its  specific  gravity  normal  or  higher  than  normal,  albu- 
min in  very  small  quantities,  few  or  no  hyaline  casts. 

Chronic  Congestion  followed  by  Chronic  Nephritis  with  Exudation. 
— The  cardiac  symptoms  more  severe  ;  the  dropsy  well  marked  ; 
the  urine  scanty,  its  specific  gravity  normal  or  lowered,  a  large 
quantity  of  albumin,  and  casts  in  variable  number. 

Chronic  Congestion  followed  by  Chronic  Nephritis  without  Exuda- 
tion.— -The  patients  are  liable  to  have  attacks  of  contraction  of 
the  arteries.  The  dropsy  is  not  as  constant.  The  quantity  of 
the  urine  varies,  sometimes  above,  sometimes  below  the  normal. 
Its  specific  gravity  is  low.  There  is  but  little  albumin  except 
when  the  arteries  are  contracted.  Loss  of  flesh  and  'strength  are 
marked  features. 

Chronic  Degeneration.  —  The  cardiac  symptoms  are  severe  ; 
dropsy  is  regularly  present,  but  not  always  marked.  The  quan- 
tity of  the  urine  varies,  its  specific  gravity  is  unchanged,  there  is 
but  little  albumin.  The  patients  are  feeble  and  anaemic  Avith  a 
prolonged  period  of  scanty  urine,  delirium,  stupor,  and  the  ty- 
phoid state. 

Chronic  Degeneration  followed  by  Chro?iic  Nephritis  with  Exuda- 
tion.— The  cardiac  symptoms  are  severe  arid  the  dropsy  well 
marked.  The  quantity  of  urine  is  small,  its  specific  gravity  is 
rather  high  than  low.  Albumin  is  present  in  large  quantities, 
casts  are  not  as  constant.  The  patients  are  feeble,  anaemic,  and 
get  worse  rapidly. 

Chronic  Nephritis  either  with  or  ivithotit  Exudation,  not  preceded 
by  Congestion — In  these  patients  there  is  the  ordinary  history  of 
chronic  nephritis  lasting  for  months  or  years.  Then,  as  the  en- 
docarditis advances,  the  heart's  action  becomes  worse  and  the 
circulation  is  disturbed,  the  different  cardiac  symptoms  are 
added. 

Treatment.— K\\XiO\x^h.  we  are  unable  to  remove  the  mechani- 
cal interference  with  the  circulation,  yet  the  condition  of  the  pa- 
tients can  often  be  very  much  improved.  The  main  indications 
are  to  improve  the  character  of  the  circulation  and  to  remove 
the  dropsy.  In  order  to  improve  the  circulation  it  is  absolutely 
necessary  to  study  the  character  of  the  heart's  action,  to  appre- 
ciate the  organic  changes  in  the  heart,  and  to  determine  whether 
the  walls  of  the  arteries  are  thickened,  and  whether  there  is  an 
increase  or  diminution  of  the  arterial  tension.     It  is  unfortunate 


THE    URINE.  295 

that  there  is  no  instrument  to  tell  us  certainly  what  the  arterial 
tension  is  ;  we  have  to  depend  upon  the  sense  of  touch.  This, 
however,  can  be  educated,  and  a  physician  is  not  competent  to 
manage  cardiac  cases  if  he  cannot  appreciate  changes  in  arterial 
tension. 

In  many  patients  with  an  irregular  heart,  dyspnoea,  and  dropsy, 
simple  rest  is  of  the  greatest  service.  This  is  especially  marked 
in  hospital  patients  who  have  tried  to  work  up  to  the  time  of 
their  admission.  It  is  often  a  good  rule  to  give  no  medicine  to 
such  patients  until  we  see  how  much  they  improve  with  rest 
alone. 

The  regulation  of  the  food  is  of  importance.  It  is  to  be  re- 
membered that,  while  gastric  indigestion  and  flatulence  make 
the  heart-action  worse,  on  the  other  hand  meat  is  one  of  the  best 
cardiac  stimulants.  Most  patients  are  better  for  meat  in  some 
form  at  least  once  a  day. 

Tumultuous  and  exaggerated  heart-action  may  be  due  to  con- 
traction of  the  arteries  and  require  such  drugs  as  nitro-glycerin 
or  chloral  hydrate.  It  may  be  the  expression  of  a  heart  which  is 
really  feeble  and  requires  digitalis.  It  may  mean  a  real  exagger- 
ation of  the  muscular  action  of  the  heart  and  be  benefited  by 
aconite,  belladonna,  and  the  local  action  of  cold.  A  feeble  heart 
without  contraction  of  the  arteries  calls  for  cardiac  stimulants  ; 
digitalis,  strophanthus,  and  caffeine  are  the  best.  But  it  is  to  be 
remembered  that  with  aortic  and  mitral  stenosis,  myocarditis, 
and  diseased  coronary  arteries,  there  comes  a  time  when  cardiac 
stimulants  make  the  heart's  action  worse  instead  of  better.  This 
is  the  time  for  the  use  of  opium.  Small  doses  of  codeine  or  of 
morphine  give  the  patient  more  relief  than  can  be  obtained  in 
any  other  way. 

In  many  patients  the  condition  of  the  heart  and  arteries  varies 
from  day  to  day,  so  that  there  have  to  be  many  corresponding 
changes  and  combinations  of  the  drugs — the  cardiac  stimulants, 
the  arterial  dilators,  and  the  opium. 

The  dropsy  is  more  or  less  favorably  affected  by  the  rest  in 
bed  and  the  regulation  of  the  circulation.  It  can  also  be  reduced 
by  the  hot  pack  and  the  hot-air  bath. 

For  very  extensive  cardiac  dropsies,  with  only  chronic  con- 
gestion of  the  kidney  or  but  little  nephritis,  calomel  is  the  most 
efficient  diuretic.  Three  grains  of  calomel  with  -^j  of  a  grain  of 
morphine,   four  times  a   day  for  four  days,   is   the  dose.     The 


296  ACUTE   DEGENERATION. 

mouth  and  gums  are  to  be  kept  ver\  clean.  If  the  drug  acts  prop- 
erly there  is  but  little  effect  on  the  bowels  and  no  salivation,  but 
on  the  third  day  the  quantity  of  urine  increases  and  remains  large 
for  several  days.  The  dropsy  diminishes  and  may  disappear  al- 
together. 

Acute  Degeneration  of  the  Kidneys, 
definition. 

An  acute  change  in  the  kidneys,  characterized  by  degenera- 
tion or  death  of  the  epithelial  cells  of  the  tubules,  to  which  may 
be  added  an  exudation  from  the  blood-vessels. 

Synonyms. — Acute  Bright's  disease  ;  Parenchymatous  Nephri- 
tis ;  Parenchymatous  Degeneration. 

ETIOLOGY. 

The  introduction  of  certain  poisons  into  the  body  is  regularly 
followed  by  changes  in  the  cells  of  the  viscera.  The  poisons 
which  exert  this  effect  are  ordinarily  mineral  poisons,  such  as 
arsenic,  mercury,  and  phosphorus  ;  or  the  poisons  of  infectious 
diseases,  such  as  diphtheria,  typhoid  fever,  etc.  According  to 
the  quantity  and  virulence  of  the  poison  received  into  the  body, 
there  are  more  or  less  marked  changes  produced  in  the  cells  of 
the  viscera. 

Small  doses  of  such  poisons,  acting  only  for  a  moderate  length 
of  time,  produce  simple  swelling  of  the  cells.  The  cells  are 
swollen,  more  opaque,  more  coarsely  granular.  They  are  not 
dead,  nor  broken  down,  nor  do  they  contain  any  new  substances  ; 
the  change  in  their  appearance  is  due  to  the  swelling  of  the  net- 
work which  forms  a  part  of  every  cell.  Under  these  circum- 
stances there  are  either  no  changes  at  all  in  the  blood-vessels  of 
the  viscera,  or  a  slight  congestion,  with,  perhaps,  a  little  exuda- 
tion of  serum. 

Larger  doses  of  such  poisons,  or  more  virulent  poisons,  or  a 
longer  duration  of  the  action  of  a  poison,  are  attended  by  the 
deposition  in  the  cell-bodies  of  granules  of  albuminous  matter 
and  globules  of  fat.  At  the  same  time  there  is  a  change  in  the 
nutrition  of  the  cells,  and  they  are  often  broken  and  disinte- 
grated. Under  these  conditions  there  may  be  considerable  con- 
ofestion  of  the  vessels  and  an  exudation  of  serum. 


ACUTE   DEGENERATION.  29/ 

Very  large  doses  of  such  poisons  cause  the  death  of  the  cells 
of  the  viscera,  a  death  which  may  take  the  form  of  coagulation- 
necrosis  or  of  disintegration  and  breaking  down  of  the  cell. 
With  these  changes  there  will  often  be  an  excessive  congestion 
of  the  vessels  and  a  large  exudation  of  serum. 

As  the  kidneys  are  excreting  organs  it  is  rather  natural  to 
think  that  the  substances  which  cause  degeneration  of  the  renal 
epithelium  do  so  because  they  are  excreted  by  the  kidneys.  But, 
as  the  same  poisons  produce  similar  degeneration  in  many  other 
parts  of  the  body,  it  seems  more  probable  that  the  effect  of  the 
poison  is  produced  in  the  same  way  that  it  is  in  the  nerves,  the 
muscles,  the  liver,  and  the  spleen. 

The  well-known  fact  that  temporary  cutting  off  of  the  arterial 
blood  from  the  kidneys  in  animals  is  followed  by  degeneration 
or  death  of  the  renal  epithelium,  has  led  to  the  idea  that  de- 
generation of  the  kidneys,  especially  in  cholera,  is  due  to  is- 
chaemia.  This  seems  possible,  but  it  is  a  theory  not  at  all  ap- 
plicable to  most  cases  of  acute  degeneration. 

It  is  curious  that  so  many  different  poisons  should  act  in  the 
same  way.  There  seems  to  be  nothing  in  common  between  the 
poison  of  corrosive  sublimate  and  that  of  yellow  fever,  and  yet 
the  changes  in  the  kidneys  are  practically  the  same. 

The  inorganic  poisons,  arsenic,  etc.,  act  according  to  the  size 
of  the  dose  taken.  A  small  dose  produces  only  moderate  de- 
generation of  the  renal  epithelium,  a  large  dose  causes  extensive 
necrosis  with  considerable  exudation  of  blood  serum. 

The  toxins  of  the  different  infectious  diseases  vary  as  to  the 
activity  of  their  effect  on  the  renal  epithelium,  as  to  the  time  in 
the  disease  when  the  degeneration  takes  place,  and  as  to  the  fre- 
quency with  which  true  nephritis  is  produced  instead  of  acute 
degeneration.  It  is  a  question  of  much  importance  whether  the 
same  toxin  produces  degeneration  or  nephritis  according  to  its 
dose,  or  whether  two  or  more  different  toxins  are  necessary. 
In  scarlatina  and  diphtheria,  for  example,  the  rule  is  that  acute 
degeneration  comes  in  the  early  days  of  the  disease,  acute  ex- 
udative nephritis  in  the  late  days  of  the  disease,  and  acute  pro- 
ductive nephritis  just  after  the  close  of  the  disease.  Does  this 
mean  three  different  toxins,  or  that  the  same  toxin  varies  at 
different  stages  of  the  disease,  or  that  the  only  difference  is  in  the 
dose  ? 

For  clinical  purposes  the   recognition  of  the  fact   that  acute 


298  ACUTE   DEGENERATION. 

degeneration  is  the  ordinary  lesion  of  the  infectious  diseases,  is  of 
much  practical  importance. 

MORBID    ANATOMY. 

The  gross  appearance  of  the  kidney  varies  with  the  extent  of 
the  degeneration.  In  the  ordinary  mild  cases,  such  as  accompany 
pneumonia,  the  kidney  is  a  little  larger,  the  cortical  portion  a 
little  thicker  and  paler.  In  the  severe  cases,  such  as  accompany 
acute  yellow  atrophy  of  the  liver,  the  kidney  is  considerably  en- 
larged and  more  or  less  congested. 

The  changes  in  the  renal  epithelial  cells  are  :  a  simple  swell- 
ing of  the  cell-body,  causing  it  to  look  larger  and  more  opaque 
and  to  take  on  irregular  shapes  ;  an  infiltration  of  the  cell-bodies 
with  granules  of  albuminoid  matter  and  fat ;  a  death  of  the  cells, 
which  may  take  the  form  of  coagulation  necrosis  or  of  a  disin- 
tegration of  the  cell-bodies  ;  a  desquamation  of  the  dead  cells  so 
that  the  tubes  are  filled  with  them  ;  a  formation  of  hyaline  masses 
in  the  cells  ;  a  growth  of  new  cells  to  take  the  place  of  the  dead 
epithelium.  All  these  changes  are  most  marked  in  the  con- 
voluted tubes. 

In  the  kidneys  with  extensive  necrosis  of  the  epithelium  there 
may  also  be  congestion  of  the  blood-vessels  and  casts  in  the 
tubes. 

SYMPTOMS. 

With  the  severe  acute  degeneration  which  follows  the  inges- 
tion of  large  doses  of  arsenic,  mercury,  or  one  of  the  other  in- 
organic poisons,  the  urine  is  diminished  in  quantity,  or  sup- 
pressed ;  it  contains  albumin,  casts,  and  blood  ;  its  specific  gravity 
is  unchanged.  At  first  the  general  symptoms  belonging  to  the 
poison  predominate,  but  as  these  subside  the  patients  continue  to 
live  and  suffer  more  or  less  severely  from  the  degeneration  of 
the  kidney.  They  become  feeble,  pass  into  the  typhoid  state, 
and  often  die. 

The  acute  degeneration  which  accompanies  the  infectious  dis- 
eases such  as  scarlatina,  diphtheria,  typhoid  fever,  pneumonia, 
etc.,  is  for  the  most  part  of  mild  type  and  gives  no  symptoms  ex- 
cept the  presence  of  a  little  albumin  and  a  few  casts  in  the  urine. 
It  is  of  importance  to  recognize  the  frequency  with  which  this 
affection  of  the  kidney  occurs,  the  slight  injury  which  it  inflicts 
on  the   patient,   and  the   completeness   with  which  the    kidney 


CHRONIC   DEGENERATION.  299 

lesion  disappears  after  the  recovery  from  the  primary  disease. 
Mucli  unnecessary  anxiety  is  often  felt  by  physicians  because  in 
a  case  of  pneumonia  or  some  other  infectious  disease  they  find 
albumin  and  casts  in  the  urine.  There  are  fears  not  only  of 
death  from  the  primary  disease,  but  of  the  subsequent  develop- 
ment of  "  Bright's  disease."  If  the  albumin  and  casts  are  due  to 
degeneration  of  the  kidneys  anxiety  is  needless.  The  course  of 
the  primary  disease  will  not  be  changed.  If  the  patients  recover 
their  kidneys  return  to  their  normal  condition. 

With  yellow  fever,  with  acute  yellow  atrophy  of  the  liver,  and 
occasionally  with  the  other  infectious  diseases  the  degeneration  is 
of  intense  type,  with  the  death  of  a  large  part  of  the  i^enal  epithe- 
lium and  exudation  from  the  vessels.  In  such  cases  the  urine  is 
scanty  or  suppressed.  It  contains  albumin,  casts,  and  blood. 
The  patients  are  very  ill,  they  may  have  convulsions,  delirium, 
or  stupor  ;  they  often  die.  But  it  is  hard  to  tell  how  many  of 
their  symptoms  are  due  to  the  complicating  kidney  lesion. 

TREATMENT. 

So  far  as  the  degeneration  of  the  epithelium-  is  concerned, 
we  know  of  no  treatment  which  is  likely  to  affect  it  favorably.  ■ 
But  in  the  severe  cases  with  congestion  of  the  kidneys  and  scanty 
urine,  it  seems  to  be  good  practice  to  use  the  hot-air  baths  or  the 
hot  pack. 

It  is  evident  that  acute  degeneration  of  the  kidney  can  be 
sharply  distinguished  from  all  other  forms  of  kidney  disease.  It 
is  always  produced  by  the  introduction  of  some  poison  into  the 
body.  It  is  not  accompanied  by  dropsy,  contraction  of  the  ar- 
teries, or  by  other  renal  symptoms.  It  is  not  usually  dangerous 
to  life.  It  is  a  temporary  condition  not  followed  by  any  chronic 
kidney  disease.  If  the  patient  recovers  from  his  poisoning  the 
kidneys  return  to  their  normal  condition. 

Chronic  Degeneration  of  the  Kidney, 
definition. 

A  chronic  disease  of  the  kidneys  characterized  by  degenera- 
tive changes  in  the  renal  epithelium. 

Synonyms. — Chronic  Bright's  disease.  Chronic  Parenchymatous 
Nephritis,  Fatty  Kidney. 


300  CHRONIC   DEGENERATION. 


ETIOLOGY. 


The  same  mechanical  obstructions  to  the  circulation — heart 
disease,  pleuritic  effusions,  etc. — which  produce  chronic  conges- 
tion, can,  instead  of  this,  produce  chronic  degeneration  of  the 
kidney. 

It  is  said  that  anaemia  of  the  kidneys  produces  degeneration 
of  the  renal  epithelium.  Experiments  upon  animals  show  that 
this  view  is  theoretically  possible.  It  may  be  that  the  degenera- 
tion of  the  kidneys  seen  in  old  and  feeble  persons  is  due  to  a  di- 
minished blood-supply,  but  we  can  hardly  speak  with  certainty  on 
this  point. 

Chronic  diseases,  such  as  phthisis  and  cancer,  are  followed  by 
clironic  degeneration  of  the  kidneys. 

There  is  a  group  of  cases  in  which,  although  the  health  of  the 
patients  is  not  good,  it  is  not  easy  to  fix  on  a  definite  cause  for 
the  chronic  degeneration. 

Apparently  many  of  the  authors  who  describe  a  "  chronic  pa- 
renchymatous nephritis  "  include  under  this  head  botii  chronic 
degeneration  and  chronic  nephritis. 

The  matter  is  further  complicated  by  the  fact  that  kidneys 
may  be  in  the  condition  of  chronic  degeneration  for  some  time, 
and  then  become  further  altered  by  a  chronic  nephritis  with  exu- 
dation, and  by  waxy  degeneration  of  the  glomeruli. 

MORBID    ANATOMY. 

If  the  degeneration  follows  heart  disease  the  kidneys  are 
large,  weighing  together  from  sixteen  to  twenty  ounces.  Tiieir 
surfaces  are  smooth  ;  the  cortical  portion  is  thickened,  of  pink  or 
white  color,  the  pyramids  are  red.  The  gross  appearance  is  that 
of  the  so-called  large  white  kidney.  The  epithelium  of  the  cor- 
tex tubes  is  swollen  and  coarsely  granular.  The  capillaries  of 
the  glomeruli  are  dilated,  with  more  or  less  thickening  of  their 
walls.  The  veins  in  the  pyramids  are  congested.  There  are  no 
changes  in  the  stroma,  or  in  the  arteries. 

If  the  degeneration  follows  phthisis,  cancer,  or  any  wasting 
disease,  the  kidneys  are  usually  large,  with  a  white  or  yellowish 
cortex.  There  are  no  changes  except  in  the  cortex  tubes.  In 
these  the  epithelial  cells  are  either  coarsely  granular  or  infil- 
trated with  fat. 


CHRONIC   DEGENERATION.  3OI 

If  the  degeneration  occurs  in  old  people,  or  without  discover- 
able cause,  the  kidneys  may  be  either  large  and  white,  or  of  the 
size  and  appearance  of  a  normal  kidney,  or  small  and  red.  There 
are  the  same  degenerative  changes  in  the  epithelium  of  the  cor- 
tex tubes,  with  no  lesions  in  the  stroma  or  the  glomeruli. 

SYMPTOMS. 

With  the  degeneration  caused  by  heart  disease  the  quantity  of 
the  urine  varies  witli  the  changes  in  the  action  of  the  heart  and 
the  contraction  of  the  arteries,  sometimes  abundant,  sometimes 
scanty,  sometimes  suppressed.  The  specific  gravity  is  not  dimin- 
ished, nor  is  the  proportion  of  urea  to  the  ounce  diminished.  Al- 
bumin and  casts  in  small  quantities  are  more  frequently  present 
than  with  chronic  congestion.  While  it  is  difficult  to  separate  the 
kidney  symptoms  from  the  heart  symptoms,  yet  one  has  the  im- 
pression that  this  kidney  lesion  is  more  serious  than  chronic  con- 
gestion, and  has  its  effect  in  increasing  the  loss  of  nutrition  and 
the  anaemia. 

If  the  degeneration  is  followed  by  chronic  nephritis  with  exu- 
dation, albumin  appears  in  the  urine  in  large  quantities  ;  the 
anaemia  and  dropsy  are  very  marked,  and  the  patients  get  worse 
rapidly. 

When  the  degeneration  accompanies  chronic  diseases,  such 
as  phthisis  or  cancer,  the  urine  remains  normal,  or  from  time  to 
time  contains  a  little  albumin  and  a  few  casts.  The  patients  are 
so  ill  with  their  primary  disease  that  the  secondary  degeneration 
of  the  kidneys  is  hardly  appreciable  during  life. 

The  group  of  cases  in  which  the  degeneration  occurs  without 
discoverable  cause  is  interesting,  for  the  kidney  lesion  may  be 
the  cause  of  death.  It  is  a  difficult  group  to  study,  because  the 
cases  are  not  very  numerous,  and  the  clinical  histories  and  autop- 
sies are  apt  to  be  dissociated.  The  autopsies  are  for  the  most 
part  in  hospital  patients  vvitli  short  and  imperfect  histories ; 
while  the  clinical  histories  are  of  private  patients  on  whom  it  is 
difficult  to  obtain  autopsies.  I  think,  however,  that  it  can  be 
said  the  urine  remains  normal,  or  from  time  to  time  contains  a 
little  albumin  and  few  casts.  Neither  dropsy,  nor  a  pulse  of 
high  tension,  nor  a  hypertrophied  left  ventricle,  nor  acute  urae- 
mic  symptoms  are  present. 

The  patients  gradually,  month  after  month,  lose    flesh    and 


302  ACUTE   EXUDATIVE   NEPHRITIS. 

strength  and  become  more  or  less  anaemic.  They  may  have  a 
variety  of  digestive  disturbances.  The  course  of  the  disease  is 
slow,  sometimes  interrupted  by  periods  of  improvement,  but  reg- 
ularly getting  worse  from  year  to  year.  Finally  the  patients  are 
so  feeble  that  they  remain  in  bed  ;  they  develop  alternating  de- 
lirium and  stupor,  and  so  die. 

The  diagnosis  in  these  cases  is  extremely  difficult.  They  re- 
semble cases  of  malignant  disease  in  which  no  tumor  can  be 
found,  and  cases  of  chronic  nephritis  with  normal  urine  and  no 
changes  in  the  heart  or  arteries. 

TREATMENT. 

It  is  not  easy  to  find  means  to  influence  chronic  degenera- 
tion of  the  renal  epithelium.  The  best  that  we  can  do  for  the 
patients  is  to  stop  all  vicious  habits,  to  regulate  the  diet  and  mode 
of  life,  and  to  relieve  the  disturbances  of  circulation. 

Acute  Exudative  Nephritis. 

definition. 

An  acute  inflammation  of  the  kidneys,  characterized  by  con- 
gestion, exudations  of  the  blood-plasma,  emigration  of  white 
blood  cells,  diapedesis  of  red  blood-cells,  to  which  may  be  added 
changes  in  the  renal  epithelium  and  in  the  glomeruli. 

Synonyms. — Acute  Bright's  Disease  ;  Parenchymatous  Nephri- 
tis ;  Tubal  Nephritis  ;  Desquamative  Nephritis  ;  Catarrhal  Ne- 
phritis ;  Croupous  Nephritis  ;  Glomerulo-nephritis. 

ETIOLOGY. 

Acute  exudative  nephritis  is  frequently  a  primary  inflam- 
mation, occurring  either  after  exposure  to  cold  or  without  dis- 
coverable cause.  It  may  complicate  any  one  of  the  infectious  in- 
flammations or  diseases,  but  is  especially  common  with  scarlet 
fever.  It  is  one  of  the  forms  of  nephritis  which  are  caused  by 
pregnancy. 

Acute  exudative  inflammation  in  any  part  of  the  body  seems 
to.be  caused  by  local  irritation,  by  the  presence  of  irritating  sub- 
stances in  the  blood,  and  by  changes  in  the  circulation  of  the 
blood  and  in  the  inflamed  portion  of  the  body.     Pathogenic  bac- 


ACUTE    EXUDATIVE    NEPHRITIS.  303 

teria  are  sometimes  present,  sometimes  absent  in  the  inflamed 
tissue. 

Unquestionably,  all  the  infectious  diseases  are  often  com- 
plicated with  inflammations  of  different  parts  of  the  body.  The 
probable  causes  of  these  are  the  chemical  poisons  produced  by 
the  growth  of  the  pathogenic  bacteria  belonging  to  each  disease. 
It  seems  also  that  the  poison  of  each  disease  has  a  preference  for 
particular  portions  of  the  body,  In  rheumatism  the  joints  and 
heart  are  regularly  inflamed  ;  in  measles,  the  bronchi  ;  in  scarlet 
fever  and  diphtheria  the  throat  and  the  kidneys. 

As  regards  the  presence  of  bacteria  in  the  kidneys  themselves 
as  exciting  causes  of  inflammation,  our  knowledge  is  uncertain. 

Whether  nephritis  in  puerperal  w^omen  and  after  exposure  to 
cold  is  due  to  disturbances  of  circulation  or  to  some  poison  in 
the  blood  is  not  certain. 

There  are  marked  differences  in  the  severity  of  different  cases 
of  nephritis.  The  exudation  of  serum  is  larger  in  one  case,  the 
emigration  of  white  blood-cells  in  another.  In  one  kidney  the 
epithelial  cells  are  contracted,  in  another  they  are  swollen  and 
degenerated.  The  glomeruli  are  much  more  changed  in  some 
kidneys  than  in  others.  How  closely  these  differences  in  the 
lesions  correspond  to  differences  in  the  causation  of  the  nephritis, 
we  do  not  know. 

MORBID    ANATOMY. 

In  a  nephritis  of  this  type  we  should  expect  that  the  inflam- 
matory products,  the  serum,  white  and  red  blood-cells,  and  coag- 
ulable  matter  from  the  blood-plasma  would  collect  in  the  Mal- 
pighian  bodies  and  tubes  or  infiltrate  the  stroma  between  the 
tubes,  and  that  of  the  inflammatory  products  in  the  tubes  and 
Malpighian  bodies,  a  part  would  be  discharged  with  the  urine 
and  a  part  be  found  in  the  kidney  after  death.  We  should  also 
expect  that  the  quantity  of  inflammatory  products  would  be  in 
proportion  to  the  severity  of  the  inflammation,  and  that  an  ex- 
cessive number  of  pus-cells  w^ould  belong  to  the  especially  severe 
forms  of  the  disease.  Still  further,  it  is  evident  that  with  the 
milder  examples  of  nephritis,  with  but  little  exudation,  no  in- 
flammatory products  might  be  found  in  the  kidney  after  death, 
all  having  been  discharged  into  the  urine  during  life. 

As  a  matter  of  fact,  the  kidneys  do  present  just  such  changes. 


304  ACUTE   EXUDATIVE   NEPHRITIS. 

In  the  mild  cases  we  find  no  decided  lesions  in  the  kidney  after 
death. 

In  the  more  severe  cases  the  kidneys  are  increased  in  size,  their 
surfaces  are  smooth,  the  cortical  portion  is  thick  and  white,  or 
white  mottled  with  red,  or  the  entire  kidney  is  intensely  congested. 
If  the  stroma  is  infiltrated  with  serum,  the  kidney  is  succulent 
and  wet ;  if  the  number  of  pus-cells  is  very  great,  there  will  be 
little  whitish  foci  in  the  cortex. 

In  such  kidneys  we  find  the  evidence  of  exudative  inflamma- 
tion in  the  tubes,  the  stroma,  and  the  glomeruli,  all  the  changes 
being  most  marked  in  the  cortical  portion  of  the  kidney. 

The  epithelium  of  the  convoluted  tubes  is  often  simply 
flattened.  As  this  same  appearance  is  also  found  in  the  chronic 
congestion  of  heart  disease,  it  seems  probable  that  this  change 
of  the  shape  of  the  cells  is  merely  due  to  the  inflammatory  con- 
gestion. 

In  other  cases,  not  only  is  the  epithelium  flattened,  but  there 
is  also  a  real  dilatation  of  the  cortex  tubes.  This  dilatation  in- 
volves groups  of  tubes  or  all  the  cortex  tubes  uniformly. 

In  other  cases  the  epithelium  of  the  convoluted  tubes  is 
swollen,  opaque,  degenerated,  and  detached  from  the  tubes. 

The  tubes,  whether  with  flattened  epithelium  or  dilated,  may 
be  empty.  More  frequently,  however,  they  contain  coagulated 
matter  in  the  form  of  irregular  masses  and  of  hyaline  cylinders. 
The  irregular  masses  are  found  principally  in  the  convoluted 
tubes  ;  they  seem  to  be  formed  by  a  coagulation  of  substances 
contained  in  the  exuded  blood-plasma,  and  are  not  to  be  con- 
founded with  the  hyaline  globules  so  often  found  in  normal  con- 
voluted tubes.  The  cylinders  are  more  numerous  in  the  straight 
tubes,  but  are  also  found  in  the  convoluted  tubes.  They  also  are 
evidently  formed  of  matter  coagulated  from  the  exuded  blood- 
plasma,  and  are  identical  with  the  casts  found  in  the  urine. 

The  tubes  may  also  contain  red  and  white  blood-cells. 

In  the  cases  in  which  there  is  an  excessive  emigration  of 
white  blood-cells,  we  find  these  cells  in  the  tubes,  in  the  stroma, 
or  distending  the  capillary  veins.  This  excessive  emigration  is 
not  necessarily  attended  with  exudation  of  the  blood  serum,  and 
so  the  urine  of  these  patients  may  contain  no  albumin.  The 
white  blood-cells  are  not  usually  found  equally  diffused  through 
the  kidneys,  but  are  collected  in  foci  in  the  cortex.  These  foci 
may  be  very  minute  or  may  attain  a  considerable  size. 


ACUTE   EXUDATIVE   NEPHRITIS.  305 

The  glomeruli  regularly  are  changed.  The  cavities  of  the 
capsules  may  contain  coaguhited  matter  and  white  and  red  blood- 
cells,  just  as  do  the  tubes.  The  capsular  epithelium  may  be 
swollen,  sometimes  so  much  so  as  to  resemble  the  tubular  epithe- 
lium, and  this  change  is  most  marked  in  the  capsular  epithelium 
near  the  entrance  of  the  tubes. 

The  most  noticeable  change,  iiowever,  is  in  the  capillary  tufts 
of  the  glomeruli.  These  capillaries  are  normally  covered  on 
their  outer  surface  by  flat,  nucleated  cells,  so  that  the  tuft  is  not 
made  up  of  naked  capillaries,  but  each  separate  capillary 
througliout  its  entire  length  is  covered  over  with  these  cells. 
There  are  also  fiat  cells  which  line  the  inner  surfaces  of  the 
capillaries,  although  not  uniformly,  as  is  the  case  in  capillaries 
in  other  parts  of  the  body.  Still,  in  spite  of  the  presence  of 
all  these  cells,  the  outlines  of  the  walls  of  the  capillaries  are 
fairly  distinct. 

In  exudative  nephritis  the  swelling  and  growth  of  cells  on 
and  in  the  capillaries  change  the  appearance  of  the  glomeruli. 
Tiiey  are  larger,  more  opaque,  the  outlines  of  the  main  divis- 
ions of  the  tuft  are  visible,  but  those  of  the  individual  capil- 
laries are  lost. 

It  is  difficult  to  tell  how  much  these  changes  in  the  glome- 
ruli interfere  with  the  passage  of  the  blood  through  their  capil- 
laries. 

In  most  cases  of  exudative  nephritis  the  patients  recover, 
and  the  glomeruli  return  to  their  natural  condition. 

In  some  examples  of  exudative  nephritis  we  also  find  a  thick- 
ening of  the  walls  of  the  branches  of  the  renal  artery  within 
the  kidney.  This  thickening  is  principally  due  to  a  swelling  of 
the  muscle-cells  in  the  walls  of  these  vessels. 

All  these  changes  in  the  kidneys  are  of  such  a  character 
that  they  are  not  likely  to  be  followed  by  a  chronic  nephritis. 
On  the  contrary,  after  the  patients  have  recovered,  the  kidneys 
return  to  their  normal  condition. 

SYiMPTOMS. 

I.  There  are  cases  of  acute  nephritis  of  so  mild  a  character 
that  they  may  easily  be  overlooked.  I  think  that  these  mild 
cases  occur  more  frequently  than  is  commonly  supposed.  The 
patients  are  hardly  sick  enough  to  go  to  bed.     They  iiave  a  little 


-306  ACUTE   EXUDATIVE   NEPHRITIS. 

headache,  perhaps  some  aching  in  the  baclv  and  limbs,  loss  of 
appetite,  a  little  nausea,  and  the  feeling  of  general  malaise. 
They  often  think  that  they  have  taken  cold.  These  indefinite 
symptoms  last  for  one  or  two  weeks,  disappear,  and  the  patient 
is  well  again.  If  the  urine  is  not  examined  it  is  not  known 
that  the  patient  has  been  suffering  from  a  mild  nephritis.  If 
the  urine  is  examined  it  is  found  that  the  quantity  is  some- 
what diminished,  the  specific  gravity  is  not  lowered,  an  ap- 
preciable quantity  of  albumin  is  present,  with  hyaline,  granular, 
and  epithelial  casts,  sometimes  with  red  and  white  blood-cells. 
If  the  number  of  blood-cells  is  sufficient  to  color  the  urine,  the 
patient's  attention  is  attracted  by  the  change  in  color ;  the  di- 
minished quantity  he  is  apt  not  to  notice.  These  changes  in 
the  urine  last  for  four  or  five  weeks  and  then  disappear. 

2.  The  ordinary  cases  of  acute  exudative  nephritis  vary  in- 
deed in  their  severity,  but  all  give  characteristic  symptoms.  The 
only  diseases  with  which  they  can  be  confounded  are  :  acute  pro- 
ductive nephritis  and  exacerbations  of  a  chronic  nephritis.  If 
any  person  seems  to  have  several  attacks  of  acute  nephritis,  it 
regularly  means  that  he  has  a  chronic  nephritis  with  exacerba- 
tions. 

The  quantity  of  urine  is  diminished  at  the  onset  of  the  ne- 
phritis, and  continues  small  until  the  activity  of  the  inflammation 
has  subsided  ;  then  the  quantity  increases  from  day  to  day  and 
may  even  exceed  the  normal.  The  quantity  of  the  urine  must  be 
in  proportion  to  the  quantity  of  blood  which  passes  through  the 
kidneys,  so  that  this  quantity  gives  us  a  measure  of  the  intensity 
of  the  congestion  which  is  arresting  the  circulation  of  the  blood 
through  the  kidney.  Complete  suppression  of  urine  is  a  serious 
symptom,  both  because  it  denotes  an  intense  nephritis  and  be- 
cause it  is  of  itself  a  cause  of  death.  The  production  of  only  a 
few  ounces  of  urine  in  each  twenty-four  hours  is  the  rule  in  a 
great  number  of  cases,  and  is  not  necessarily  of  serious  import. 
If  it  only  lasts  a  few  days  the  patients  do  perfectly  well.  If  the 
scanty  excretion  of  urine  is  kept  up  for  a  number  of  days,  opin- 
ions vary  as  to  the  results.  Some  believe  that  the  diminished 
quantity  of  urine  is  the  cause  of  the  dropsy.  Some  think  that 
the  deficient  excretion  of  excrementitious  substances  causes  the 
convulsions.  Some  believe  that  the  principal  effect  of  a  dimin- 
ished excretion  of  urine  is  to  cause  bodily  feebleness. 

Unquestionably,  the   production  of  urine  may  be  very  small 


ACUTE  p:xljuative  nephritis.  307 

for  a  number  of  days  and  yet  the  patients  do  well.  Dr.  Whitelaw 
{Lancet,  September  29,  1877)  reports  a  case  of  anuria,  lasting  for 
twenty-five  days.  The  patient  was  a  boy  eight  years  of  age. 
The  suppression  of  urine  began  twelve  weeks  after  the  beginning 
of  a  scarlet  fever.  With  the  exception  of  two  ounces  passed  on 
the  thirteenth  day,  there  was  complete  anuria  for  twenty-five  days. 
Except  for  slight  headaches  and  later  slight  oedema,  there  were 
no  uraemic  or  dropsical  symptoms  throughout.  There  was  no 
albuminuria  and  no  fever.  The  boy  was  watched  night  and  day. 
He  recovered  entirely. 

The  specific  gravity  of  the  urine  remains  normal  or  is  higher 
while  the  quantity  is  small  ;  when  the  quantity  is  increased  the 
specific  gravity  falls  a  little. 

The  appearance  of  the  urine  is  turbid,  or  smoke-colored,  or 
bloody. 

Albumin  is  present  in  very  large  quantities.  Casts  are  numer- 
ous— hyaline,  granular,  nucleated,  epithelial,  and  blood.  There 
are  also  red  and  white  blood-cells,  and  epithelial  cells  from  the 
kidneys  and  from  the  bladder.  As  a  rule  the  quantity  of  albumin 
and  the  number  of  casts  are  in  proportion  to  the  severity  of  the 
nephritis,  but  this  is  not  always  the  case.  Large  quantities  of 
albumin,  numerous  casts,  and  many  red  and  white  blood-cells 
may  be  found  in  the  urine  of  kidneys  which,  after  death,  show  no 
structural  changes  except  in  the  glomeruli.  While,  on  the  other 
hand,  small  quantities  of  albumin  and  a  few  hyaline  casts  are 
compatible  with  a  severe  nephritis.  Still  further,  the  number  of 
casts  found  in  the  urine  during  life  is  not  always  in  proportion 
to  the  number  of  casts  found  in  the  corresponding  kidneys  after 
death. 

The  characteristic  symptoms  of  acute  exudative  nephritis  are  : 
a  febrile  movement,  with  more  or  less  prostration  ;  headache, 
stupor,  sleeplessness,  restlessness,  muscular  twitching,  general 
convulsions;  dyspnoea,  loss  of  appetite,  nausea  and  vomiting;  a 
pulse  of  high  tension  with  exaggerated  heart  action,  or  hyper- 
trophy of  the  left  ventricle  ;  dropsy  and  anaemia. 

When  acute  nephritis  complicates  scarlet  fever  or  one  of  the 
other  infectious  diseases,  the  patient  may  already  have  a  febrile 
movement  belonging  to  the  primary  disease.  If  the  nephritis  is 
primary,  or  if  it  is  not  developed  until  the  fever  belonging  to  the 
original  disease  has  subsided,  there  is  a  rise  of  temperature  be- 
longing to  the   nephritis.     This   fever  is   in   proportion    to    the 


308  ACUTE    EXUDATIVE   NEPHRITIS. 

severity  of  the  nephritis,  and  in  children  is  sometimes  as  high  as 
105°  F.  The  fever,  however,  does  not  usually  continue  more  than 
a  week,  although  the  nephritis  lasts  longer. 

Headache,  restlessness,  sleeplessness,  delirium,  and  stupor 
during  the  first  days  of  an  acute  nephritis  seem  to  be  of  the 
same  nature  as  they  are  in  so  many  severe  inflammations  at- 
tended with  fever.  But  later  in  the  disease,  after  the  temperature 
has  fallen,  they  apparently  depend  upon  the  increased  tension  in 
the  arteries.  In  the  cases  of  prolonged  anuria,  however,  there  is 
a  condition  of  mild  delirium  and  stupor  with  a  soft  pulse. 

General  convulsions  are  of  not  uncommon  occurrence,  espe- 
cially in  children.  They  do  not  usually  occur  until  after  the  ne- 
phritis has  existed  for  several  days.  They  are  often  preceded  by 
involuntary  contractions  of  groups  of  muscles.  They  may  be  pre- 
ceded and  followed  by  stupor.  The  frequency  of  their  occur- 
rence does  not  seem  to  be  in  direct  relation  to  the  quantity  of 
urine  excreted.  They  may  be  absent  in  fatal  anuria,  and  present 
when  the  quantity  of  urine  is  nearly  normal.  It  is  the  rule  be- 
fore and  during  the  convulsions  to  have  a  marked  increa.se  in  the 
tension  of  the  pulse.  While  general  convulsions  are  an  alarming 
symptom,  yet  a  great  many  children  make  a  very  good  recovery 
after  having  them. 

Loss  of  appetite,  nausea,  and  vomiting  at  the  beginning  of 
the  nephritis  seem  to  be  due  to  the  febrile  movement.  Later  in 
the  disease  it  is  probable  that  they  are  due  to  the  disturbance  of 
the  function  of  the  kidneys. 

A  pulse  of  high  tension,  exaggerated  contractions  of  the 
heart,  and  sometimes  hypertrophy  of  the  left  ventricle  are 
present  in  some  of  the  cases,  not  by  any  means  in  all  of  them. 
This  disturbance  of  the  circulation  is  evidently  caused  by  con- 
traction of  the  arteries.  That  the  contraction  of  the  arteries  is 
due  to  the  presence  of  irritating  substances  in  the  blood  is  prob- 
able, but  not  certain. 

Dropsy  is  present  in  many  of  the  cases.  It  is  usually  con- 
fined to  the  subcutaneous  connective  tissue.  Its  probable  causes 
have  already  been  discussed. 

Anaemia,  with  a  pallor  of  the  skin  out  of  proportion  to  the 
diminution  in  the  quantity  of  haemoglobin,  is  very  often  seen. 
We  are  still  ignorant  as  to  the  way  in  which  an  acute  nephritis 
causes  such  changes  in  the  composition  of  the  blood. 

3.  Acute  exudative  nephritis  with  an  excessive  production  of 


ACUTE   EXUDATIVE   NEPHRITIS.  309 

pus-cells.  This  is  not  to  be  confounded  with  embolic  nephritis, 
nor  with  nephritis  caused  by  cystitis.  It  is  only  a  severe  variety 
of  acute  exudative  nephritis.  It  is  seen  both  in  children  and  in 
adults.  I  have  seen  it  with  scarlatina,  diphtheria,  and  measles, 
and  occurring  without  discoverable  cause. 

The  invasion  is  sudden,  with  a  high  temperature  and  marked 
prostration.  Restlessness,  headache,  delirium,  and  stupor  are 
soon  developed  and  continue  throughout  the  disease.  The 
patients  rapidly  lose  flesh  and  strength  and  pass  into  the  typhoid 
state.  Dropsy  is  slight  or  absent  altogether.  The  urine  is  not 
so  much  diminished  in  quantity  as  one  would  expect.  Its  specific 
gravity  is  not  changed.  Albumin,  casts,  and  red  and  white  blood- 
cells  are  present  in  considerable  quantities,  but  not  always  early 
in  the  disease,  and  they  may  even  be  absent  altogether. 

Although  this  form  of  nephritis  is  not  of  common  occurrence, 
the  unusual  characters  of  the  symptoms  and  the  great  mortality 
are  reasons  for  calling  special  attention  to  it.  It  differs  from  the 
ordinary  form  of  exudative  nephritis  in  that  it  behaves  like  an 
infectious  inflammation,  and  that,  although  the  emigration  of 
white  blood-cells  is  large,  the  exudation  of  serum  may  be  small, 
and  so  the  urine  may  show  but  little  changes.  It  is  probable 
that  the  nephritis  is  the  result  of  some  obscure  form  of  bacte- 
ritic  infection. 

The  ordinary  duration  of  an  acute  exudative  nephritis,  which 
germinates  favorably,  is  about  four  weeks,  but  may  extend  to 
eight.  The  recovery  is  a  complete  one,  and  there  is  no  danger 
that  chronic  nephritis  will  follow. 

PROGNOSIS. 

The  patients,  who  for  three  or  four  weeks  have  only  the  fever, 
prostration,  loss  of  appetite,  nausea,  anaemia,  dropsy,  and  changes 
in  the  urine,  as  a  rule  recover  completely  and  are  not  at  any 
time  in  real  danger. 

The  development  of  the  cerebral  symptoms — the  stupor, 
headache,  sleeplessness,  restlessness,  and  general  convulsions — 
always  causes  anxiety,  but  yet  even  of  these  patients  the  larger 
number  get  entirely  well.  The  cases  with  an  excessive  produc- 
tion of  pus-cells  differ  from  all  the  other  forms  of  acute  exuda- 
tive nephritis,  and  are  very  fatal. 


3IO  ACUTE    EXUDATIVE    NEPHRITIS. 


TREATMENT. 

We  have  to  treat  an  acute  exudative  inflammation  of  the  liid- 
neys,  which  naturally  runs  its  course  in  four  weeks  and  termi- 
nates in  recovery.  We  have  also  to  treat  the  symptoms  of  this 
nephritis — the  scanty  urine,  dropsy,  vomiting,  anaemia,  and  cere- 
bral symptoms.  We  have  to  treat  these  conditions  more  fre- 
quently in  children  than  in  adults,  and  very  often  as  complicat- 
ing an  infectious  disease. 

The  most  efficient  treatment  of  the  nephritis  is  the  application 
of  heat  to  the  entire  surface  of  the  body.  This  can  be  done  in  a 
number  of  ways,  but  the  best  way  is  to  wrap  the  entire  body  in  a 
blanket  wrung  out  of  hot  water.  Such  a  hot  pack  can  be  used 
for  an  hour  at  a  time  once  or  twice  a  day.  Of  drugs  the  most 
reliable  is  aconite — one  or  two  minims  of  the  tincture  every  hour. 
It  mav  be  necessary  to  precede  the  aconite  by  giving  one 
drachm  of  sulphate  of  magnesia  every  hour  until  the  bowels 
move,  or  until  eight  doses  have  been  taken.  There  are  cases,  in 
which  the  nephritis  is  not  of  very  acute  type,  where  digitalis 
seems  to  exert  a  favorable  effect  on  the  circulation.  The  prefer- 
able form  of  the  drug  is  digitalin  in  doses  of  one  one-hundreth 
of  a  grain. 

The  scanty  urine  often  causes  anxiety.  Of  course  it  is  better 
that  the  patients  should  pass  a  fair  quantity  of  urine,  but  I  think 
that  there  is  a  tendency  to  exaggerate  the  dangers  of  scanty 
urine  and  to  be  too  energetic  in  giving  diuretics.  As  the  dimi- 
nution in  the  quantity  of  urine  is  due  to  the  congestion  of  the 
kidneys,  if  we  can  decrease  the  congestion  the  urine  will  increase. 
The  best  way  to  do  this  is  to  apply  heat  to  the  surface  of  the 
body.  The  use  of  diuretics  is  to  be  avoided.  The  attempts  to 
make  up  for  the  scanty  production  of  urine  by  purging  or  sweat- 
ing the  patient  have  never  seemed  to  me  to  be  of  any  practical  use. 

The  febrile  movement  in  an  acute  nephritis  requires  no  treat- 
ment. 

The  prostration,  loss  of  appetite,  nausea,  and  vomiting  ojply 
call  for  rest  in  bed  and  a  fluid  diet. 

The  anaemia  ought  to  be  prevented  or  relieved,  but  while 
the  nephritis  is  still  active  I  know  of  no  way  in  which  this  can 
be  done.  When  convalescence  is  established,  then  the  anaemia 
readily  improves  with  the  ordinary  methods  of  treatment. 


ACUTE    EXUDATIVE    NEPHRITIS.  3II 

The  dropsy  is  subcutaneous,  and  even  when  considerable, 
does  little  harm.  It  disappears  of  itself  as  the  nephritis  sub- 
sides. The  rest  in  bed  and  the  hot  pack  are  all  the  treatment 
necessary  for  it.  To  give  diuretics  or  cathartics  to  get  rid  of  the 
dropsy  is  quite  useless. 

The  cerebral  symptoms  are  the  ones  to  which  most  attention 
has  been  directed.  There  can  be  no  question  that  they  accom- 
pany a  contraction  of  the  arteries  with  increased  arterial  tension 
and  labored  action  of  the  heart.  No  matter  what  views  one  mav 
entertain  as  to  the  cause  of  this  change  in  the  circulation,  I 
believe  that  treatment  is  best  directed  to  the  arteries  themselves, 
rather  than  to  the  uncertain  causes  of  their  contraction.  Fortu- 
nately there  are  drugs  which  stop  contraction  of  the  arteries 
promptly  and  efficiently.  Of  these  drugs  the  most  suitable  are  : 
aconite,  nitro-glycerin,  chloral  hydrate,  and  opium,  preferably 
given  in  small  doses  and  at  regular  intervals  before  the  cerebral 
symptoms  are  marked,  but  in  large  doses  hypodermically  or  b}^ 
the  rectum  to  stop  a  severe  attack. 

It  is  wise  to  watch  the   condition   of  the   heart  and   arteries, 
and   as  soon  as  increased   arterial  tension   is  developed,  not   to' 
wait  for  the  manifestation  of  the  cerebral  symptoms,  but  to  try  to 
relieve  it  at  once. 

The  way  in  which  we  manage  the  patients,  therefore,  is  as 
follows  :  They  are  put  to  bed  or  kept  in  the  house  until  the 
nephritis  has  run  its  course.  They  are  put  on  a  fluid  diet,  pref- 
erably milk,  and  the  skin  of  the  entire  body  is  cleaned  once  a 
day.      For  many  cases  no  other  treatment  is  necessary. 

If  vomiting  is  troublesome  it  can  usually  be  controlled  by 
adding  oxalate  of  cerium  and  bicarbonate  of  soda  to  the  milk. 
For  the  restlessnsss  and  sleeplessness  chloral  hydrate,  the  bro- 
mides, or  opium  may  be  employed. 

If  the  nephritis  is  of  severe  type  the  patient  is  wrapped  in  a 
blanket  wrung  out  of  hot  water  and  kept  in  it  for  one  hour 
either  once  or  twice  every  day.  In  addition  we  give  one  drachm 
of  sulphate  of  magnesia  every  hour  until  the  patient  has  taken 
eight  doses  or  the  bowels  begin  to  move.  This  is  followed  by 
one  or  two  minims  of  tincture  of  aconite  every  hour. 

Throughout  the  disease  we  watch  the  pulse,  and  as  soon  as  it 
shows  any  increased  tension  give  chloral  hydrate  in  doses  of 
from  two  to  five  grains  every  three  hours. 

If  severe  headache,   muscular  twitchings,  or  general  convul- 


312  ACUTE   PRODUCTIVE   NEPHRITIS. 

sions  occur,  to  most  of  the  patients  we  give  chloral  hydrate  in 
doses  of  from  5  to  20  grains  by  the  rectum,  or  nitro^glycerin  in 
doses  of  from  ^^  to  -^-^  of  a  grain  hypodermically,  or  morphine 
in  doses  of  from  ^^  to  -|-  of  a  grain  hypodermicallv.  In  strong 
and  robust  adults  with  a  good  deal  of  venous  congestion,  general 
blood-letting  may  be  advisable.  For  the  relief  of  the  convul- 
sions urethane  in  solution,  given  in  repeated  doses  up  to  100 
grains  in  twenty-four  hours,  is  said  to  be  of  service. 

As  the  nephritis  subsides  the  milk  is  gradually  replaced  by 
solid  food,  and  iron  and  oxygen  are  given. 

Acute  Productive  (or  Diffuse)  Nephritis, 
definition. 

An  acute  inflammation  of  the  kidneys,  characterized  by  exu- 
dation from  the  blood  vessels,  a  growth  of  new  connective  tissue 
in  the  stroma,  and  changes  in  the  epithelium  and  the  glomeruli. 

Synonyms. — Acute  Bright's  Disease  ;  Parenchymatous  Nephri- 
tis ;  Croupous  Nephritis  ;  Glomerulo-nephritis. 

ETIOLOGY. 

This  is  the  most  serious  and  important  of  the  forms  of  acute 
nephritis,  for  the  reason  that  its  lesions  are  from  tlie  first  of  a 
permanent  character.  It  does  not  follow  exudative  nepliritis, 
nor  is  it  merely  a  modification  of  it ;  from  the  very  outset  it  is 
a  different  form  of  inflammation.  In  the  kidneys  of  persons  who 
have  been  sick  only  a  few  days,  the  characteristic  lesions  are 
already  evident.  Productive  nephritis  is  governed  by  the  same 
law  as  that  which  belongs  to  productive  inflammation  in  other 
parts  of  the  body — the  disposition  of  the  inflammation  to  con- 
tinue as  a  subacute  and  chronic  condition.  It  is  of  importance  to 
recognize  that  in  exudative  nephritis  the  lesions  are  temporary, 
and  after  their  subsidence  the  kidneys  return  to  their  normal 
condition,  just  as  the  lungs  do  after  a  lobar  pneumonia.  In  pro- 
ductive nephritis,  on  the  other  hand,  some  of  the  lesions  are  per- 
manent, the  kidneys  can  never  return  to  their  normal  condition, 
just  as  in  an  interstitial  pneumonia  the  lung  never  gets  rid  of  the 
new  connective  tissue. 

Post-scarlatinal  nepliritis  is  nearly  always  of  the  productive 
form.      Nephritis  complicating   diphtheria  or  developed  during 


.ACUTE   PRODUCTIVE   NEPHRITIS.  313 

pregnancy  is  very  frequently  of  this  type.  A  primary  nephritis 
in  a  person  over  twelve  years  old,  if  of  subacute  form,  is  almost 
invariably  a  productive  nephritis.  On  the  other  hand,  this  form 
of  nephritis  very  seldom  complicates  any  of  the  infectious  dis- 
eases except  scarlatina  and  diphtheria. 

These  facts  assist  very  much  in  making  the  diagnosis  between 
the  two  forms  of  acute  nephritis.  It  is  easy  to  remember  that 
post-scarlatinal  nephritis  and  primary  nephritis  of  subacute  type 
are  nearly  always  of  the  productive  form  ;  and  that  nephritis 
with  diphtheria  and  pregnancy  is  often  of  the  productive  form  ; 
while  acute  nephritis  under  all  other  conditions  is  regularlv  of 
the  exudative  form. 

MORBID    ANATOMY. 

The  kidneys  are  increased  in  size,  the  capsules  are  not  ad- 
herent, the  surfaces  are  smooth.  The  cortical  portion  is  red,  or 
white,  or  mottled.  The  mucous  membrane  of  the  pelvis  is  some- 
times congested.  Of  the  tubules  in  the  cortex,  in  some  the 
epithelium  is  flattened,  in  some  there  is  coagulated  matter  or 
casts,  in  some  the  epithelium  is  swollen,  degenerated,  or  con- 
tains globules  of  fat.  In  those  parts  of  the  cortex  where  there  is 
a  growth  of  new  connective  tissue,  the  tubes  may  be  atrophied. 
The  tubules  of  the  pyramids  show  but  little  change  except  that 
they  may  contain  casts.  In  the  stroma  of  the  cortex  there  is  a 
growth  of  new  connective  tissue,  varying  in  different  kidneys  as 
to  the  relative  proportion  of  cells  and  basement  substance. 
This  new  tissue  in  many  of  the  kidneys  follows  the  line  of  the 
arteries  which  run  up  into  the  cortex,  so  that  it  takes  the  form 
of  wedges.  But  in  other  kidneys  the  new  tissue  is  diffuse,  or  in 
irregular  patches. 

Many  of  the  glomeruli  show  only  an  increase  in  the  size  and 
number  of  the  cells  which  cover  the  capillaries,  with  some 
swelling  of  the  capsule  cells.  But  in  others  there  is  an  extensive 
new-growth  of  capsule  cells  which  compresses  the  tuft  of  vessels. 
This  growth  of  new  cells  from  the  capsule  cells  must  not  be 
confounded  with  accumulations  of  white  blood-cells  within  the 
capsules,  nor  with  the  growth  of  new  cells  on  the  walls  of  the 
capillaries.  The  glomeruli  which  are  changed  in  this  way  are  in 
groups,  each  group  corresponding  to  some  one  artery. 

The  whole  picture  of  the  nephritis  is  that  of  a  combination  of 
exudative  and  productive  inflammation. 


314  ACUTE   PRODUCTIVE   NEPHRITIS. 

When  such  a  nephritis  becomes  chronic  it  is  often  possible  to 
follow  its  course  for  many  years,  and  to  see  at  the  end  of  that 
time  that  the  anatomical  changes  in  the  kidney  are  of  the  same 
kind,  but  much  more  extensive. 


SYMPTOMS. 

Of  the  patients  who  suffer  from  this  form  of  nephritis,  a  cer- 
tain number  behave  as  if  they  had  a  simple  exudative  nephritis. 
There  is  a  rise  of  temperature  with  more  or  less  prostration. 
Cerebral  symptoms  are  marked — headache,  stupor,  sleepless- 
ness, restlessness,  muscular  twitchings,  and  general  convulsions. 
The  arteries  are  contracted,  the  pulse  is  of  high  tension,  the 
heart's  action  is  exaggerated,  the  left  ventricle  may  be  hyper- 
trophied,  there  is  dyspnoea.  The  appetite  is  lost,  there  may  be 
nausea  and  vomiting.  The  urine  is  scanty  or  suppressed,  it  is 
colored  by  blood,  and  contains  much  albumin  and  many  casts. 
The  patients  are  very  sick  and  much  more  likely  to  die  than 
they  are  with  an  exudative  nephritis. 

Such  a  nephritis  ma)'-,  however,  apparently  run  its  course. 
At  the  end  of  four  weeks  the  symptoms  subside  and  the  patients 
get  better.  They  may  then  remain  in  ordinary  health  without 
renal  symptoms  for  weeks,  months,  or  years.  But  sooner  or 
later  the}--  have  another  acute  attack,  or  they  gradually  develop 
the  symptoms  of  a  chronic  nephritis. 

The  more  ordinary  cases  have  a  gradual  invasion,  and  run  a 
subacute  rather  than  an  acute  course. 

In  some  of  the  patients  at  first  there  are  only  loss  of  appe- 
tite, headaches,  and  an  increasing  pallor  of  the  skin  and  mucous 
membranes ;  the  dropsy  does  not  come  on  until  after  many  days. 

In  some  of  the  patients  dropsy  of  the  legs  is  the  first  and,  for 
a  time,  the  only  symptom.  They  continue  to  eat  well,  feel  well, 
and  attend  to  their  work. 

In  most  of  the  patients  dropsy  of  the  legs  and  face,  anaemia, 
headache,  sleeplessness,  loss  of  appetite,  nausea  and  vomiting 
are  developed  at  about  the  same  time. 

The  urine  is  only  moderately  diminished  in  quantity  ;  it  often 
contains  no  blood,  there  is  a  large  quantity  of  albumin  and  a 
considerable  number  of  casts.  The  specific  gravity  remains 
normal,  or  falls  a  little. 

The  cases  vary  a  good  deal  as  to  their  severity 


ACUTE   PRODUCTIVE   NEPHRITIS.  315 

Some  of  the  patients  are  not  at  any  time  very  sick.  A  mod- 
erate subcutaneous  oedema,  anaemia,  headache,  and  disturbances 
of  digestion  last  for  a  few  weeks,  tlien  disappear,  and  the  pa- 
tients seem  to  be  well.  Some  of  them  do  get  well,  but  the  ma- 
jority either  liave  other  attacks  of  the  same  character,  or  develop 
the  symptoms  of  chronic  nephritis.  It  is  surprising  for  how 
many  years  some  of  these  patients  go  on  in  apparent  good  health, 
although  the  kidneys  are  really  becoming  more  and  more  dis- 
eased. 

In  some  patients  the  dropsy  is  much  more  extensive  and  in- 
volves the  serous  cavities  as  well  as  the  subcutaneous  tissue. 
For  a  number  of  weeks  these  patients  are  in  bed  and  very  badly 
off.  And  yet  even  the  bad  attacks  may  subside  altogether,  the 
patients  are  apparently  well,  are  able  to  go  back  to  their  work, 
and  have  no  more  trouble  for  years. 

In  some  patients  there  is  first  a  well-marked  attack  of  dropsy, 
anaemia,  headache,  sleeplessness,  loss  of  appetite,  nausea  and 
vomiting,  which  lasts  for  a  few  weeks.  Then  the  symptoms  sub- 
side and  the  patients  are  pretty  well,  but  not  very  well.  After 
this  they  have  attacks  of  the  same  kind  at  intervals  of  weeks  or 
months,  and  this  may  go  on  for  years.  In  hospital  patients  the 
attacks  regularly  come  on  every  winter,  and  the  patients  are 
comparatively  well  in  the  summer.  Each  attack,  however,  is 
worse  than  the  preceding,  and  finally  there  comes  an  attack 
which  proves  fatal.  In  these  long  cases  the  specific  gravity  of 
the  urine  becomes  lower  from  year  to  year. 

The  severe  and  progressive  cases  are  most  distressing  to  wit- 
ness. The  patients  are  constantly  getting  worse,  and  yet  months 
may  elapse  before  their  sufferings  are  terminated  by  death. 
The  color  of  the  skin  and  of  the  mucous  membranes  becomes 
more  and  more  white  ;  headaches  are  constant  and  trouble- 
some ;  sleep  is  difficult  and  unrefreshing  ;  the  eyesight  is  im- 
paired or  lost  altogether  ;  there  is  no  appetite,  but  rather  con- 
stant nausea  and  irritability  of  the  stomach  ;  from  time  to  time 
the  arteries  are  contracted  and  there  is  a  disposition  to  muscular 
twitchings  and  general  convulsions.  The  dropsy  constantly  in- 
creases, no  matter  how  large  the  excretion  of  urine.  The  subcu- 
taneous connective  tissue  is  everywhere  oedematous  and  the 
serous  cavities  are  filled  with  serum.  It  seems  as  if  the  blood 
serum  was  unable  to  remain  in  the  vessels,  it  escapes  every  where. 


3l6  ACUTE   PRODUCTIVE   NEPHRITIS. 


PROGNOSIS. 

The  majority  of  cases  of  acute  productive  nephritis  terminate 
unfavorably.  Either  the  disease  goes  on  continuously  and  the 
patients  die  at  the  end  of  a  few  days  or  a  few  months  ;  or  the 
acute  symptoms  subside  and  a  chronic  nephritis  supervenes.  It 
is  not  wise,  however,  to  give  too  unfavorable  a  prognosis  even  in 
severe  cases  ;  great  improvement  and  even  complete  recovery 
are- possible.  I  see  from  time  to  time  persons  in  apparently  good 
health  and  able  to  earn  their  living,  concerning  whom  I  have 
given  a  very  unfavorable  prognosis  many  years  ago. 

TREATMENT. 

In  those  cases  in  which  the  disease  behaves  like  an  acute  ex- 
udative nephritis  the  indications  for  treatment  are  the  same  as  in 
the  latter  disease,  although  the  results  are  not  as  satisfactory. 

The  subacute  cases  have  to  be  managed  differently.  At  first 
it  is  wise  to  keep  the  patients  in  bed  and  on  an  exclusively  milk 
diet.  In  some  of  the  patients  the  daily  use  of  the  hot  pack 
seems  to  be  of  service  ;  in  some  nothing  is  gained  by  its  use  ;  in 
some  it  is,  I  think,  harmful.  I  do  not  know  how  to  distinguish 
the  appropriate  cases  for  the  hot  pack  except  by  trying  its  use 
for  a  few  days. 

Digitalis,  preferably  in  the  form  of  digitalin  in  doses  of  y^-g 
of  a  grain,  seems  in  some  of  the  cases  to  exert  a  favorable  effect 
on  the  nephritis.  At  all  events  the  quantity  of  the  albumin  in 
the  urine  diminishes  and  the  patients  improve  ;  but  in  some  cases 
it  does  nothing.  In  the  same  way  morphine  in  small  doses, 
sometimes  not  more  than  j\  of  a  grain,  relieves  the  headache, 
sleeplessness,  and  nausea,  and  the  patients  are  evidently  better 
for  it.  But  there  are  other  patients  to  whom  the  morphine  is 
of  no  service  whatever. 

The  dropsy  is  always  of  consequence.  It  is  associated  with  a 
soft  pulse  ;  a  faint  heart  action,  rather  feeble  than  forcible  ;  no 
great  disposition  to  venous  congestion.  The  composition  of  the 
blood  is  profoundly  changed  by  the  diminution  in  the  quantity 
of  hsemoglobin  and  the  number  of  red  blood-cells,  and  probably 
in  other  ways  which  we  do  not  appreciate.  The  quantity  of 
urine  may  be  either  diminished  or  increased.     The  dropsy,  there- 


ACUTE    PRODUCTIVE    NEPHRITIS.  317 

fore,  does  not  seem  to  depend  on  changes  in  the  blood  pressure 
or  in  the  quantity  of  urine,  but  rather  on  changes  in  the  com- 
position of  the  blood  or  in  the  walls  of  the  arteries.  It  is  a 
dropsy  which  it  is  very  difficult  to  treat  intelligently. 

There  are  cases  in  which  the  dropsy  will  disappear  simply 
with  tlie  rest  in  bed  and  the  milk  diet. 

There  are  cases  in  which  profuse  sweating  by  the  hot-air  bath 
or  the  hot  pack  diminishes  the  dropsy.  But  some  of  these 
patients  cannot  be  made  to  sweat,  some  of  them  are  too  much 
depressed  by  the  he.at,  in  some  the  sweating  does  not  diminish 
the  dropsy. 

Hydragogue  cathartics,  such  as  jalap  and  elaterium,  will  often 
diminish  the  dropsy  for  a  time.  Their  use,  however,  cannot  be 
continued  for  any  length  of  time  without  irritating  the  stomach 
and  intestines. 

The  daily  use  of  good  massage  with  compression  of  the  legs 
by  bandages  is  sometimes  of  real  value. 

Digitalis,  caffeine,  and  strophanthus  in  many  cases  act  effi- 
ciently, even  when  they  do  not  increase  the  quantity  of  urine. 
They  are  the  most  useful  drugs  for  this  particular  purpose. 

The  use  of  diuretics  is  limited  to  the  cases  in  which  the  quan- 
tity of  urine  is  diminished.  In  a  patient  with  increasing  dropsy, 
who  is  already  passing  90  or  100  ounces  of  urine  a  day,  diuretics 
are  not  indicated.  The  drugs  ordinarily  employed  to  effect 
diuresis  are  those  which  act  on  the  circulation — digitalis,  caffeine, 
strophanthus,  and  convallaria  ;  and  those  which  are  supposed  to 
act  on  the  kidneys — acetate  of  potash,  lactate  of  strontium,  squills, 
diuretin.  Good  results  are  reported  from  the  use  of  those  drugs. 
But  experience  shows  that  in  some  patients  the  quantity  of  urine 
cannot  be  increased,  and  in  others  the  increase  in  the  quantity  of 
urine  is  not  followed  by  diminution  of  the  dropsy. 

It  would  seem  as  if  the  disposition  to  dropsy  could  be  con- 
trolled if  we  could  control  the  composition  of  the  blood,  increase 
the  number  of  the  blood-cells,  and  raise  the  specific  gravity  of 
the  blood  serum.  Unfortunately  we  do  not  know  how  to  do 
this. 

When  necessary,  to  make  the  patient  more  comfortable,  we 
have  to  tap  the  peritoneal  and  pleural  cavities  and  to  puncture 
the  skin  of  the  legs. 

If  the  patients  improve,  the  milk  diet  is  to  be  gradually  re- 
placed by  solid   food,  iron   is   to  be  given  in  fair  doses,  and  the 


3l8  CHRONIC   NEPHRITIS   WITH   EXUDATION. 

patient  gets  out  of  bed  and  out  of  the  house.  At  this  time  cli- 
mate becomes  a  matter  of  much  importance.  The  patient  should 
be  sent  to  a  warm,  dry,  equable  climate,  where  he  can  lead  an 
out-door  life. 

Chronic  Productive  (or  Diffuse)  Nephritis  with  Exudation. 

definition. 

A  chronic  inflammation  of  the  kidney  attended  with  a  growth 
of  new  connective  tissue  in  the  stroma,  permanent  changes  in 
the  glomeruli,  degeneration  of  the  renal  epithelium,  exudation 
from  the  blood-vessels,  and  sometimes  changes  in  the  walls  of 
the  arteries. 

Synonyms. — Chronic  Bright's  Disease  ;  Chronic  Parenchyma- 
tous Nephritis  ;  Chronic  Glomerulo-nephritis ;  Waxy  Kidney; 
Large  White  Kidney  ;  Chronic  Diffuse  Nephritis  ;  Chronic  Des- 
quamative Nephritis. 

It  has  been  customary  to  hold  that  in  all  these  kidneys  the  pri- 
mary and  most  important  changes  are  in  the  renal  epithelium, 
while  in  another  set  of  kidneys  the  primary  and  important 
changes  are  in  the  stroma.  In  other  words,  that  the  cases  of 
chronic  nephritis  can  be  divided  into  two  classes — parenchyma- 
tous nephritis  and  interstitial  nephritis. 

I  do  not  think  that  this  classification  is  supported  by  facts. 

In  all  the  forms  of  chronic  nephritis  changes  are  to  be  found 
in  the  renal  epithelium,  the  glomeruli,  and  the  stroma.  Whether 
the  changes  in  the  stroma,  the  glomeruli,  or  the  epithelium  are 
the  moi-e  marked  makes  no  difference  in  the  clinical  symptoms. 
But  the  presence  or  absence  of  exudation  from  the  renal  blood- 
vessels does  correspond  to  a  marked  difference  in  the  symptoms. 
The  existence  of  the  exudation  from  the  renal  vessels  is  easily 
shown  by  the  presence  of  serum  albumin  in  the  urine.  In  this 
way  we  readily  distinguish  two  forms  of  chronic  nephritis,  one 
with  exudation  and  one  without. 

The  way  of  looking  at  the  matter,  then,  is  this  : 

We  find  after  death  from  chronic  nephritis  a  great  many  va- 
rieties in  the  gross  appearance  of  the  kidneys.  Some  are  large, 
some  are  small,  some  are  red,  some  are  white,  etc.  There  is  no 
regular  correspondence  between  these  different  gross  appearances 
of  the  kidneys  and  the  clinical  symptoms. 


CHRONIC   NEPHRITIS   WITH   EXUDATION.  319 

We  find  in  these  same  kidneys  changes  in  the  renal  epithelium 
in  the  stroma,  in  the  glomeruli,  and  in  the  arteries.  Sometimes 
one,  sometimes  the  other  of  these  elements  of  the  kidneys  is  the 
most  changed.  There  is  no  regular  correspondence  between  the 
predominance  of  the  changes  in  one  of  the  kidney  elements  over 
the  other  and  the  clinical  symptoms. 

The  easiest  working  scheme  is  to  admit  that  in  chronic  ne- 
phritis all  the  elements  of  the  kidney  are  more  or  less  changed, 
but  that  the  cases  vary  as  to  whether  there  is  or  is  not  an 
exudation  of  serum  from  the  blood-vessels.  The  presence  or 
absence  of  such  an  exudation  does  correspond  to  a  well-marked 
difference  in  the  clinical  symptoms. 

In  the  present  state  of  our  knowledge  and  for  clinical  purposes, 
we  divide  all  the  cases  of  nephritis  into  two  classes,  chronic 
nephritis  with  exudation  and  chronic  nephritis  without  exuda- 
tion. 

It  is  admitted  that  it  is  easy  to  divide  up  these  kidneys,  accord- 
ing to  their  anatomical  changes,  into  a  number  of  fairly  well- 
marked  classes.  But  as  this  division  does  not  correspond  to 
clinical  divisions  it  is  valueless  for  clinical  purposes. 

Although  it  is  convenient  to  describe  two  forms  of  chronic 
nephritis — one  with  much  albuminuria  and  dropsy,  and  one  with 
little  or  no  albuminuria  or  dropsy — yet  it  must  be  remembered 
that  these  are  not  separate  lesions  of  the  kidneys,  but  varieties 
of  the  same  lesion.  For  in  all  these  kidneys  two  changes  are 
constant — productive  inflammation  of  the  glomeruli  and  stroma, 
and  degeneration  of  the  renal  epithelium.  The  only  real  differ- 
ence between  the  kidneys  is  whether,  beside  the  growth  of  new 
tissue  and  degeneration  of  renal  epithelium,  there  is  or  is  not  an 
exudation  of  serum  from  the  blood-vessels  of  the  kidneys. 

In  speaking  of  the  exudation  of  serum  from  the  vessels  and 
its  presence  in  the  urine,  we  speak  of  it  as  it  occurs  during  the 
whole  course  of  the  disease,  and  not  as  it  occurs  for  short  periods. 
We  mean  that  in  an  exudative  chronic  nephritis  there  is  usually 
a  large  quantity  of  albumin  in  the  urine,  but  that  there  may  be 
periods  during  which  the  albumin  diminishes  or  entirely  disap- 
pears. In  the  same  way,  in  a  non-exudative  nephritis  there  may 
be  periods  during  which  albumin  is  present  in  considerable 
quantities  Generally  speaking,  the  character  of  the  clinical 
symptoms  will  vary  with  the  presence  or  absence  of  tlie  albumin.' 


320  CHRONIC    NEPHRITIS    WITH    EXUDATION. 


ETIOLOGY. 

A  considerable  number  of  cases  of  chronic  nephritis  follow 
an  attack  of  acute  or  subacute  productive  nephritis.  The  con- 
ditions of  chronic  congestion  and  chronic  degeneration  of  the 
kidney  are  not   infrequently  followed  by  a  true  nephritis. 

Syphilis,  chronic  tubercular  inflammation  of  any  part  of  the 
body,  chronic  endocarditis,  and  chronic  suppurative  inflamma- 
tions are  often  complicated  with  chronic  nephritis. 

It  is  very  difficult  to  find  a  satisfactory  cause  for  the  primarv 
cases.  There  are  many  of  these,  especially  in  young  and  middle- 
aged  adults.  The  nephritis  is  developed  in  a  slow,  insidious  way 
in  persons  whose  previous  health  had  been  good,  and  in  whom  no 
exciting  cause  is  discoverable. 


MORBID    ANATOMY. 

Gross  Appearance  of  the  Kidney. — There  is  considerable  variety 
in  the  gross  appearance  of  the  kidneys.  The  types  which  I  have 
seen  most  frequently  are  as  follows  : 

1.  Large  white  kidneys,  weighing  together  sixteen  ounces  or 
more,  the  capsule  adherent  or  not,  the  surface  smooth  or  nodu- 
lar, the  cortex  thick  and  white,  tlie  pyramids  large  and  red. 

2.  Large  mottled  kidneys.  These  resemble  the  large  white 
kidneys  in  every  respect  except  that  the  cortex,  instead  of  being 
white,  is  mottled  in  a  variety  of  ways  with  white,  yellow,  red, 
and  gray. 

3.  Kidneys  which  resemble  types  one  and  two,  but  are  not  en- 
larged, the  kidneys  together  not  weighing  over  nine  ounces. 

The  majority  of  the  kidneys  in  chronic  nephritis  follow  these 
three  types. 

4.  Small  kidneys,  weighing  together  not  more  than  five 
ounces,  the  capsules  adherent  or  not,  the  surfaces  nodular,  the 
cortex  thin,  atrophied,  white,  the  pyramids  rather  large  and  red. 
These  kidneys  belong  to  persons  who  have  had  symptoms  of  kid- 
ney disease  for  many  years,  with  periods  of  apparent  recovery. 

5.  Kidneys  which  have  the  ordinary  appearance  and  consist- 
ence of  the  chronic  congestion  due  to  heart  disease,  but  in  addi- 
tion the  capsules  are  adherent  and  the  surfaces  finely  nodular. 

6.  Kidneys  of  different  sizes — -large,  medium-sized,  and  small, 


CHRONIC   NEPHRITIS    WITH    EXUDATION.  32 1 

with  adherent  capsules  and  nodular  surfaces.  The  cortex  is 
gray,  or  gray  mottled  with  red.  The  kidneys  do  not  look  at  all 
like  the  large  white  kidneys.  This  is  a  type  of  frequent  occur- 
rence. 

7.  Kidneys  which  in  their  size,  color,  and  general  appearance 
are  hardly  to  be  distinguished  from  normal  kidneys,  except  that 
their  capsules  are  adherent. 

8.  Kidneys  of  small  size,  weighing  together  not  more  than 
four  ounces,  with  adherent  capsules.  The  cortex  is  atrophied 
red,  and  irregular.  These  kidneys  are  found  in  persons  who 
have  given  symptoms  of  kidney  disease  for  a  number  of  vears. 

.  It  might  naturally  be  supposed  that  such  marked  differences 
in  the  gross  appearance  of  the  kidneys  would  correspond  to 
equally  marked  differences  in  the  clinical  histories  and  minute 
lesions.  This,  however,  is  not  the  case.  The  clinical  histories 
are  practically  interchangeable,  and  the  minute  lesions  are  essen- 
tially the  same. 

Alid'oscopical  Appearances. — If  we  make  vertical  sections  of  the 
cortex  of  all  these  kidneys,  no  matter  what  their  size  or  color,  we 
get  with  a  low  magnifying  power  the  same  general  picture.  In- 
stead of  the  uniform  and  orderly  arrangement  of  tubes  and 
glomeruli  which  we  see  in  the  normal  kidney,  the  tubes  seem  to 
be  obliterated  in  some  places  and  dilated  in  othera  There  is  a 
growth  of  fibro-cellular  tissue  in  regular  wedges,  in  irregular 
patches,  or  diffuse  between  the  tubules. 

If  we  examine  the  different  constituents  of  the  kidney  in  de- 
tail we  find  : 

The  tubes  are  in  some  places  of  normal  size,  in  some  places 
atrophied,  in  some  places  dilated.  The  atrophied  tubes  are  in 
the  patches  of  new  connective  tissue.  The  dilated  tubes  are  not 
very  large,  nor  do  they  form  cysts. 

The  epithelium  of  the  tubes  is  in  some  places  merely  flat- 
tened. These  tubes  are  empty,  or  contain  coagulated  matter,  casts, 
and  red  and  white  blood-cells.  In  other  tubes  the  epithelium 
is  more  or  less  swollen,  sometimes  so  much  so  as  to  completely 
fill  the  tubes.  In  still  other  tubes  the  epithelial  cells  are  swollen, 
their  reticulum  is  very  coarse  with  large  meshes,  and  they  are 
infiltrated  with  fat.  The  kidneys  vary  as  to  which  of  these 
changes  in  the  epithelium  predominates,  but  all  of  them  may 
be  found  in  the  same  kidney. 

The   new  connective  tissue  is   in  the  form  of  wedge-shaped 


322  CHRONIC   NEPHRITIS    WITH   EXUDATION. 

masses  in  the  cortex  which  follow  the  line  of  the  straight  arteries 
and  veins,  or  it  is  in  irregular  masses,  or  it  is  arranged  diffusely 
so  as  to  separate  the  tubes  from  each  other.  The  longer  the  ne- 
phritis lasts,  the  greater  is  the  quantity  of  new  connective  tissue. 
The  relative  proportion  of  basement  substance  and  cells  and  the 
density  of  the  basement  substance  vary  in  the  different  kidneys. 
The  new  tissue  is  well  supplied  with  blood-vessels. 

The  glomeruli  are  changed  in  several  different  ways  : 

1.  They  resemble  the  glomeruli  in  acute  exudative  nephritis. 
They  are  large,  the  convolutions  of  the  capillaries  are  seen  with 
difficulty,  there  is  a  very  great  increase  in  the  number  of  the 
cells  which  cover  the  capillaries,  but  these  new  cells  are  not  of 
large  size.  We  also  see  glomeruli,  which  apparently  have  been 
of  this  type,  small  and  atrophied. 

2.  There  is  an  increase  not  only  in  the  number,  but  also  in  the 
size,  of  the  cells  which  cover  the  capillaries.  These  cells  are  so 
large  that  they  project  outward  from  the  surface  of  the  glome- 
rulus. There  is  also  an  increase  in  the  size  and  number  of  the 
cells  within  the  capillaries.  These  glomeruli  are  found  in  all 
stages  of  atrophy. 

3.  The  capillaries  are  changed  in  the  same  way  by  a  growth 
of  large  cells  on  their  outer  surfaces  and  within  them.  In  addi- 
tion there  is  a  very  extensive  cell-growth  beginning  in  the  cells 
which  line  the  capsule.  The  mass  of  new  cells  produced  in  this 
way  may  be  so  great  as  to  compress  the  capillaries.  The  glome- 
ruli also  become  atrophied,  the  capillaries  are  shrunken,  and  the 
capsule  cells  changed  into  cormective  tissue. 

4.  If  chronic  congestion  of  the  kidneys  is  followed  by  chronic 
nephritis,  the  dilatation  of  the  capillaries  due  to  the  congestion 
continues,  and  there  is  added  an  increase  in  the  size  and  number 
of  the  cells  which  cover  the  capillaries. 

5.  The  walls  of  the  capillaries  are  the  seat  of  waxy  degenera- 
tion, while  the  cells  which  cover  them  are  increased  in  size  and 
number. 

6.  Besides  the  atrophied  glomeruli  already  described,  there 
are  others  which  are  small  and  shrunken,  with  comparatively 
little  new  growth  of  cells. 

The  arteries  Q.VQ.  not  infrequently  much  altered  by  inflammatory 
chanees.  There  is  a  growth  of  cells  and  basement  substances 
from  the  inner  surface  of  the  artery  which  obstructs  its  lumen  ; 
or  there  is  a  thickening  of  each  of  the  three  coats  of  the  arterv  ; 


CHRONIC    NEPHRITIS    WITH    EXUDATION.  323 

or  all  the  coats  of  the  artery  are  thickened  and  converted  into  a 
uniform  mass  of  dense  connective  tissue  ;  or  the  wall  of  the 
artery  undergoes  waxy  degeneration. 

SYMPTOMS. 

The  urine  varies  in  quantity  at  different  times  in  the  course  of 
the  disease.  In  the  earlier  periods  the  urine  is  often  scanty  or 
even  suppressed.  If  the  disease  goes  on  rapidly  the  quantity  of 
urine  may  continue  small  ;  if  it  goes  on  slowly  the  quantity  is 
often  increased.  In  some  of  the  worst  cases,  with  general  dropsy, 
the  patients  will  pass  more  than  one  hundred  ounces  of  urine  adav. 

The  specific  gravity  and  the  proportion  of  urea  to  the  ounce 
of  urine  slowly  diminish  as  the  disease  progresses.  This  is  the 
rule,  but  there  are  exceptions  to  it.  In  cases  which  improve 
the  quantity  of  urea,  after  being  much  diminished,  may  increase 
until  the  patient  excretes  the  full  normal  quantity  for  the  twenty- 
four  hours. 

In  the  cases  of  shorter  duration  the  specific  gravity  is  apt  to 
run  between  1.012  and  1.020.  In  the  very  chronic  cases  it  will  be 
between  i.ooi  and  1.005.  ^  very  low  specific  gravity  indicates  a 
large  growth  of  connective  tissue  in  the  stroma  of  the  cortex,  or 
waxy  degeneration  of  the  capillaries  of  the  glomeruli  and  of  the 
arteries  of  the  kidney.  Many  persons  who  think  that  they  have 
kidney  disease  get  into  the  habit  of  drinking  large  quantities  of 
mineral  waters.  This,  of  course,  gives  them  urine  of  low  specific 
gravity.  In  all  doubtful  cases  it  is  necessary  to  determine  the 
quantity  of  the  whole  excretion  of  urea  for  the  twenty-four 
hours.  There  are  patients  in  whom  the  quantity  of  urea  is  the 
principal  factor  in  enabling  one  to  decide  between  albuminuria 
without  nephritis  and  chronic  nephritis  with  exudation. 

The  urine  regularly  contains  albumin  and  casts.  During  the 
active  periods  of  the  disease  the  quantity  of  albumin  is  very 
large  ;  in  the  slow,  prolonged  cases  the  quantity  is  much 
smaller,  and  at  times  it  may  disappear  altogether.  Generally 
speaking,  with  large  quantities  of  albumin  the  patients  are 
dropsical  and  anaemic  ;  with  small  quantities  of  albumin  they  are 
anaemic  but  not  dropsical.  There  seems  to  be  a  common  cause 
for  the  exudation  of  serum  from  the  blood-vessels  throughout 
the  entire  body,  the  serum  infiltrating  the  tissues,  accumulating 
in  the  serous  cavities,  and  mixing  with  the  urine. 


324  CHRONIC   NEPHRITIS   WITH   EXUDATION. 

The  number  of  casts  is  regularly  in  proportion  to  the  quan- 
tity of  albumin,  but  there  are  exceptions  to  this  rule. 

A  peculiar  pallor  of  the  skin  and  white  color  of  the  sclerotic 
is  seldom  absent.  This  gives  to  the  patient  a  face  very  char- 
acteristic of  chronic  nephritis.  In  making  a  diagnosis  in  doubt- 
ful cases  a  good  deal  of  importance  is  to  be  attached  to  the 
presence  or  absence  of  this  appearance  of  the  face.  The  change 
in  the  color  corresponds  to  a  diminution  in  the  quantity  of 
haemoglobin  and  in  the  number  of  red  blood-cells.  These 
changes  in  the  blood  are  often  not  far  advanced,  but  sometimes 
they  are,  and  some  patients  even  die  with  the  symptoms  of  per- 
nicious anaemia. 

Dropsy  may  be  considered  almost  a  constant  symptom  of 
chronic  exudative  nephritis.  There  is  an  infiltration  of  the  sub- 
cutaneous connective  tissue  with  serum  and  an  accumulation  of 
serum  in  the  serous  cavities.  The  position  of  the  fluid  varies 
with  that  of  the  patient,  accumulating  in  the  dependent  portion 
of  the  body.  There  is  much  variety  as  to  the  extent  of  the 
dropsy.  In  some  patients  there  is  never  anything  more  than 
a  moderate  oedema  of  the  legs,  while  in  others  a  marked  general 
dropsy  is  the  most  prominent  symptom  of  the  disease.  There  is 
also  a  variety  as  to  the  time  of  appearance  and  the  duration  of 
the  dropsy.  It  may  be  one  of  the  first  symptoms  of  the  ne- 
phritis, or  it  may  not  occur  until  late  in  the  disease.  When  it  is 
once  established  it  may  never  leave  the  patient,  or  it  may  appear 
and  disappear  at  irregular  intervals. 

Many  of  the  patients  are  troubled  with  headache  and  sleep- 
lessness. In  some  of  them  these  symptoms  exist  only  when  the 
pulse  is  of  high  tension  and  disappear  when  the  pulse  becomes 
soft.  In  others,  however,  the  headache  and  sleeplessness  persist 
with  a  soft  pulse.  It  must  not  be  forgotten  that  these  symptoms 
may  also  depend  on  digestive  disturbances,  and  not  on  the  dis- 
ease of  the  kidneys. 

Acute  urce.mic  attacks  with  contraction  of  the  arteries,  dyspnoea. 
vomiting,  convulsions,  etc.,  may  occur  at  any  time  in  the  course 
of  a  chronic  exudative  nephritis.  But  they  are  of  very  much 
more  frequent  occurrence  with  the  non-exudative  form  of  the 
disease. 

Chronic  urce?nia,  on  the  contrary,  is  one  of  the  ordinary  ways 
in  which  an  exudative  nephritis  proves  fatal.  The  condition  be- 
longs  to  the   later  stages  of  the  disease.     It  is  developed  rather 


CHRONIC    NEPHRITIS    WITH    EXUDATION.  325 

gradually,  but  when  once  established  is  permanent,  not  disap- 
pearing up  to  the  time  of  the  patient's  death.  The  patients  are 
in  a  condition  of  alternating  delirium  and  stupor,  with  a  rapid, 
feeble,  soft  pulse. 

Simple  netiro-reiinitis,  or  nephritic  retinitis,  may  be  developed  at 
any  time  in  the  disease.  Both  eyes  are  regularly  involved.  The 
impairment  of  vision  may  be  very  slight,  or  considerable,  or  the 
patients  may  become  entirely  blind.  With  such  a  neuro-retinitis 
the  prognosis  of  the  nephritis  is  especially  bad. 

Dyspncea  is  a  nearly  constant  symptom,  but  it  is  not  always  the 
same  kind  of  dyspnoea,  nor  produced  by  the  same  causes.  It 
may  be  due  to  hydrothorax,  to  cedema  of  the  lungs,  to  contrac- 
tion of  the  arteries,  or  to  failure  of  the  heart's  action. 

The  dyspnoea  due  to  contraction  of  the  arteries  is  common  to 
both  forms  of  chronic  nephritis.  It  may  be  developed  at  any 
time  during  the  course  of  the  disease.  It  comes  on  in  attacks, 
especially  at  night  and  in  the  early  morning,  and  is  worse  when 
the  patients  lie  down.  It  often  begins  while  the  patient  is  ap- 
parently in  good  healtli,  but  is  a  sure  premonition  of  serious  dis- 
ease. 

In  some  cases  these  attacks  of  dyspnoea  can  be  controlled  and 
the  patient  kept  apparently  well  for  months  and  even  years.  But 
as  the  attacks  are  repeated,  they  are  more  severe  and  more  stub- 
born. The  heart's  action  fails  in  addition  to  the  contraction  of 
the  arteries,  and  the  dyspnoea  becomes  of  such  a  character  that 
it  can  only  be  relieved  by  death. 

In  other  patients  the  first  attack  of  dyspnoea  is  also  the  last- 
It  cannot  be  relieved  by  any  treatment,  and  continues  up  to  the 
time  of  the  patient's  death. 

A  catarrhal  bronchitis  with  cough  and  expectoration  is  some- 
times an  annoying  symptom.  The  cough  fatigues  the  patient, 
and  it  is  difficult  to  control  it. 

Loss  of  appetite,  nausea  and  iwmiting  are  frequent  symptoms. 
When  they  do  not  already  exist  it  is  easy  to  cause  them  by  the 
use  of  improper  drugs. 

The  heart  is  verv  often  affected.  The  disease  of  the  kidneys 
after  a  time  produces  hypertrophy  of  the  left  ventricle.  This 
does  no  harm  until  the  time  comes  when  the  heart's  action  fails 
in  spite  of  the  hypertrophy,  then  the  dyspnoea  and  the  dropsy 
follow. 

Chronic  endocarditis,   clironic  myocarditis,  and  dilatation  of 


326  CHRONIC   NEPHRITIS    WITH   EXUDATION. 

the  ventricles  are  associated  with  chronic  nephritis  in  two  ways  : 
They  may  cause  a  chronic  congestion  or  degeneration  of  the  kid- 
ney which  is  afterward  followed  by  a  nephritis  ;  or  the  heart  dis- 
ease and  kidney  disease  are  developed  in  the  same  person,  neither 
one  of  them  secondary  to  the  other.  In  these  patients  it  is  by 
no  means  easy  to  tell  how  much  of  the  dropsy,  the  dyspnoea,  and 
the  loss  of  nutrition  belongs  to  the  heart  disease  and  how  much 
to  the  nephritis. 

COURSE    OF    THE    DISEASE. 

There  is  hardly  any  limit  to  the  variations  of  the  disease,  but 
the  most  constant  symptoms  are  anaemia,  dropsy,  and  albiamin 
in  the  urine. 

The  following  are  some  of  the  ordinary  examples  of  this  form 
of  nephritis  : 

1.  There  are  cases  in  which  the  symptoms  are  nearly  con- 
tinuous. The  patients  begin  with  anaemia,  headache,  disturb- 
ances of  digestion,  and  a-  little  dropsy.  No  one  of  these  symp- 
toms is  at  first  very  marked  ;  the  patient  is  not  in  bed,  he  does 
not  feel  very  sick,  but  even  at  this  time  the  urine  contains  a 
large  quantity  of  albumin.  As  the  weeks  and  inonths  go  on  all 
the  symptoms  grow  worse  :  the  anaemia  is  more  profound,  the 
headaches  and  disturbances  of  digestion  more  troublesome,  the 
dropsy  involves  more  of  the  subcutaneous  tissue  and  the  serous 
cavities,  so  that  the  patient  becomes  more  and  more  helpless. 
There  may  be  intercurrent  attacks  of  acute  uraemia  with  contrac- 
tion of  the  arteries,  or  loss  of  eyesight,  or  a  troublesome  bron- 
chitis. The  ordinary  duration  of  this  form  of  the  disease  is  from 
one  to  three  years.  The  patients  die  with  the  most  extreme 
dropsy,  or  in  the  state  of  chronic  uraemia,  or  both  these  condi- 
tions exist  together. 

2.  There  are  cases  in  which  the  anaemia,  the  dropsy,  and  the 
dpspnoea  come  on  in  attacks  which  last  for  weeks  or  months. 
Between  the  attacks  the  patients  are  comparatively  well,  often 
able  to  work,  although  the  urine  always  contains  albumin.  These 
patients  often  go  on  for  a  number  of  years,  better  in  the  sum- 
mer and  worse  in  the  winter.  But  each  successive  attack  is  more 
serious  than  the  preceding,  and  finally  there  comes  an  attack 
from  which  the  patient  does  not  recover. 

3.  There  are  cases  in  which  a  number  of  years  before  death 
the  patients  have  an  attack  of  acute  or  subacute  nephritis  with 


CHRONIC    NEPHRITIS    WITH    EXUDATION.  327 

anaemia,  dyspnoea,  dropsy,  albumin  in  the  urine,  and  all  the  usual 
symptoms.  From  this  they  apparently  recover  completely  and 
seem  to  be  in  tlieir  ordinary  health.  The  urine  continues  to  con- 
tain a  little  albumin,  or  on  some  days  the  albumin  disappears 
altogether.  From  year  to  year  the  specific  gravity  slowly 
falls.  The  exudation  from  the  blood-vessels  of  the  kidneys 
stops,  but  the  chronic  productive  inflammation  of  the  kidneys 
continues.  Finally,  after  exposure,  with  an  accident,  with  a 
pneumonia,  or  w^ithout  discoverable  cause,  all  the  symptoms  of 
a  subacute  nephritis  are  rather  suddenly  developed,  and  the  pa- 
tient soon  dies. 

4.  There  are  cases  which  for  years  have  no  symptoms  ex- 
cept pallor  of  the  skin  and  mucous  membranes,  and  urine  of  low 
specific  gravity  which  habitually  contains  a  moderate  quantity 
of  albumin.  These  patients  must  not  be  confounded  with  cases 
of  simple  anaemia,  nor  with  those  of  persistent  albuminuria 
without  kidney  disease.  The  diagnosis  is  sometimes  quite  diffi- 
cult. Tlie  prognosis  in  these  patients  depends  upon  the  specific 
gravity  of  the  urine.  If  it  is  constantly  below  i.oio  the  progno- 
sis is  bad,  no  matter  how  well  the  patients  may  feel. 

5.  There  are  cases  in  which  the  first  symptom  is  the  attack  of 
spasmodic  dyspnoea.  This  may  continue  and  other  renal  symp- 
toms rapidly  develop.  More  frequently,  however,  tlie  dyspnoea 
is  palliated  or  relieved  by  treatment.  The  patient  then  goes  on 
for  months  or  years  with  occasional  attacks  of  dyspnoea,  each 
one  more  severe  and  harder  to  control,  until  finally  other  renal 
symptoms  appear, 

6.  There  are  the  cases  complicated  with  endocarditis,  myo- 
carditis, or  dilated  heart.  In  these  patients  we  have  the  associa- 
tion of  cardiac  and  renal  symptoms,  either  one  predominating. 

7.  There  are  cases  in  which  all  the  symptoms  disappear,  and 
the  urine  returns  to  its  natural  condition.  If  this  improvement 
continues  for  a  number  of  years  it  seems  probable  that  the  ne- 
phritis has  come  to  a  standstill,  and  that  enough  kidney  tissue 
has  been  left  unimpaired  to  carry  on  the  functions  of  the  organ. 

TREATMENT. 

In  the  second  and  third  groups  of  cases  just  described  the 
attacks  are  of  acute  or  subacute  character.  The  conditions  call- 
ing for  treatment  are  : 


328  CHRONIC   NEPHRITIS   WITH   EXUDATION. 

The  nephritis. 

The  albuminuria. 

The  dropsy. 

The  headache  and  sleeplessness. 

The  nausea  and  vomiting. 

The  contraction  of  the  arteries. 

The  anaemia. 

The  dyspnoea. 

For  the  nephritis  the  patient  should  be  kept  in  bed  and  placed 
on  a  fluid  diet.  He  should  have  a  hot  pack  twice  a  day,  once  a 
day,  or  every  other  day,  as  he  will  bear  it.  The  most  useful 
drugs  are  :  morphine  in  very  small  doses,  digitalin  gr.  j^tt'  '^^^ 
aconite  TT],  1-3. 

The  quantity  of  albumin  in  the  urine  can  be  diminished  by  the 
hot  pack  and  by  the  use  of  digitalin  gr.  y^-g-  four  times  a  day. 

The  dropsy  is  favorably  affected  by  the  hot  pack.  It  can  be 
sensibly  diminished  by  cathartics,  of  which  elaterium  is  perhaps 
the  best.  But  the  effect  of  cathartics  is  temporary,  and  their  use 
cannot  often  be  repeated. 

For  many  patients  digitalis  in  some  form  is  the  most  useful 
drug  for  the  dropsy,  and  it  can  be  continued  without  injury  for 
weeks  and  months.  Favorable  results  are  reported  from  the  use 
of  lactate  of  strontium  in  30-grain  doses  four  times  a  day,  and 
from  diuretin  in  5-grain  doses  three  times  a  day.  In  some  pa- 
tients caffeine,  convallaria,  or  strophanthus  will  answer  better 
than  digitalis. 

If  there  is  much  fluid  in  the  serous  cavities  it  should  be 
drawn  off  with  the  aspirator.  If  the  dropsy  of  the  subcutaneous 
connective  tissue  is  excessive  the  skin  is  to  be  pricked  and  the 
fluid  allowed  to  drain  off. 

The  headache  and  sleeplessness  may  exist  with  or  without  con- 
traction of  the  arteries.  If  the  arteries  are  not  contracted,  mor- 
phine in  very  small  doses,  codeine,  or  the  bromides  can  be  used. 
If  the  arteries  are  contracted  morphine  in  larger  doses  and  chloral 
are  the  best  drugs. 

The  nausea  and  vomiting  are  controlled  by  the  milk  diet,  or  it 
may  be  necessary  to  add  an  alkali  to  the  milk,  or  to  use  pepton- 
ized milk  or  kumyss. 

Contraction  of  the  Arteries. — The  character  of  the  radial  pulse 
and  the  heart's  action  are  to  be  constantly  watched.  We  do  not 
wait  for  the  dyspnoea,  or  vomiting,  or  convulsions  to  make  their 


CHRONIC   NEPHRITIS   WITH   EXUDATION.  329 

appearance,  but  as  soon  as  the  pulse  shows  an  increased  tension 
we  begin  with  nitro-glycerin,  chloral  hydrate,  morphine,  or  po- 
tassium iodide.  It  is  to  be  remembered  that  morphine  in  consid- 
erable doses  can  only  be  given  to  patients  with  this  form  of  ne- 
phritis when  the  arteries  are  contracted.  At  all  other  times  it  is 
very  easy  to  have  dangerous  and  even  fatal  results  with  any  prep- 
aration of  opium. 

The  ancBmia  of  chronic  nephritis  does  not  behave  like  simple 
aneemia.  Iron  is  not  a  specific  for  it,  although  it  may  be  of  ser- 
vice. The  greatest  improvement  in  the  anaemia  is  effected  by 
the  subsidence  of  the  nephritis. 

The  dyspnoea  is  dependent  either  upon  contraction  of  the  ar- 
teries or  upon  dropsy.  The  treatment  for  it,  therefore,  is  either 
the  treatment  of  dropsy  or  the  treatment  of  contraction  of  the 
arteries. 

In  these  two  groups  of  cases  treatment  carried  on  in  these 
ways  is  often  very  satisfactory.  All  the  symptoms  subside  and 
disappear.  But  it  must  be  remembered  that  the  kidneys  have 
become  changed  in  their  structure,  that  a  chronic  productive  ne- 
phritis still  continues,  that  relapses  and  exacerbations  are  to  be 
expected. 

As  the  symptoms  subside  the  patient  gets  back  to  a  solid  diet, 
is  out  of  bed,  and  then  out  of  doors.  If  it  is  possible  for  him  to 
spend  the  next  two  years  in  a  warm  climate  where  he  can  lead 
an  out-of-door  life,  the  probabilities  of  permanent  improvement 
will  be  much  greater. 

In  the  first  set  of  cases,  those  in  which  the  symptoms  continue 
and  get  steadily  v\rorse,  treatment  is  very  unsatisfactory.  We  try 
the  measures  that  have  just  been  described,  but  they  are  of  no 
avail.  We  cannot  even  alleviate  symptoms,  the  drugs  do  not 
help  at  all.  After  a  time  it  becomes  evident  that  there  is  no  use 
in  continuing  plans  of  treatment  which  do  nothing,  and  we  em- 
ploy very  little  treatment. 

The  fourth  set  of  cases  have  no  acute  attacks,  no  great  change 
in  the  general  health,  nothing  but  the  anaemia  and  the  changes 
in  the  urine.  The  management  of  these  cases  requires  much 
judgment. 

The  patients  should  have  a  liberal  and  varied  diet,  and  yet 
every  form  of  indigestion  is  to  be  guarded  against.  They  do 
best  if  they  can  live  in  a  warm  climate  all  the  year  round.  But 
even  in  an  unfavorable   climate  they  need   out-of-door   exercise. 


330  CHRONIC   NEPHRITIS   WITHOUT   EXUDATION. 

The  drugs  indicated  are  those  for  the  relief  of  indigestion,  and 
the  preparations  of  iron. 

The  patients  who  begin  with  attacks  of  dyspnoea,  without 
other  renal  symptoms,  can  often  be  relieved  and  enabled  to  work 
for  a  number  of  years.  The  dyspnoea  is  associated  with  a  pulse 
of  high  tension  ;  if  we  can  relieve  this  the  dyspnoea  disappears. 
The  best  drugs  for  this  purpose  are  nitro-glycerin,  chloral  hy- 
drate, and  potassium  iodide. 

In  the  cases  with  chronic  endocarditis,  myocarditis,  or  dilata- 
tion of  the  ventricles,  the  management  of  the  heart's  action  be- 
comes a  matter  of  great  importance. 

Chronic  Productive  Nephritis  without  Exudation. 

definition. 

A  chronic  inflammation  of  the  kidney  attended  with  a  new 
growth  of  connective  tissue  in  the  stroma,  permanent  changes  in 
the  glomeruli,  degeneration  of  the  renal  epithelium,  and  some- 
times changes  in  the  walls  of  the  arteries. 

Synonyjns. — Chronic  Bright's  Disease  ;  Cirrhosis  of  the  Kidney  ; 
Granular  Degeneration  ;  Interstitial  Nephritis  ;  Chronic  Indura- 
tive nephritis  ;  The  Arterio-sclerotic  Kidney. 

ETIOLOGY. 

While  this  form  of  nephritis  is  especially  common  in  persons 
over  forty-five  years  old,  it  is  by  no  means  rare  in  young  adults, 
and  is  occasionally  seen  in  children. 

It  seems  to  be  caused  by  chronic  alcoholism,  lead  poisoning, 
gout,  and  by  the  same  conditions  as  those  which  cause  emphy- 
sema, endocarditis,  and  cirrhosis  of  the  liver.  It  follows  chronic 
congestion  of  the  kidney,  hydro-nephrosis,  and  chronic  pyelitis. 

MORBID    ANATOMY. 

The  Kidneys. — The  larger  number  of  the  affected  organs  are 
found  after  death  to  be  diminished  in  size  ;  the  two  kidneys  to- 
gether may  not  weigh  more  than  two  ounces.  The  capsules  are 
adherent ;  the  surfaces  of  the  kidneys  are  roughened  or  nodular  ; 
the  cortex  is  thin  and  of  a  red  or  gray  color. 


CHRONIC   NEPHRITIS   WITHOUT   EXUDATION.  33 1 

A  considerable  number  of  these  kidneys,  however,  do  not  dif- 
fer in  their  size  or  appearance  from  normal  kidneys,  except  that 
their  capsules  are  adherent  and  their  surfaces  roughened. 

Occasionally  the  kidneys  are  large,  weighing  together  from 
16  to  32  ounces,  with  smooth  or  nodular  surfaces,  and  a  cortex 
of  red,  gray,  or  white  color. 

If  the  nephritis  follows  chronic  congestion,  the  kidneys  re- 
main hard,  but  the  cortex  becomes  thinned,  the  capsules  adhe- 
rent, and  the  surface  roughened. 

There  is  a  growth  of  new  connective  tissue  in  the  cortex  and 
also  in  the  pyramids,  which  becomes  more  and  more  extensive 
as  the  disease  goes  on.  In  the  cortex  the  new  tissue  follows  the 
distribution  of  the  normal  subcapsular  areas  of  connective  tissue, 
is  in  the  form  of  irregular  masses,  or  is  distributed  diffusely  be- 
tween the  tubes.  In  the  pyramids  the  growth  of  new  connective 
tissue  is  diffuse. 

The  tubes,  both  in  the  cortex  and  pyramids,  undergo  marked 
changes.  Those  included  in  the  masses  of  connective  tissue  are 
diminished  in  size,  their  epithelium  is  flattened,  some  contain 
cast  matter,  many  are  obliterated.  The  tubes  between  the  masses 
of  new  connective  tissue  are  more  or  less  dilated  ;  their  epithe- 
lium is  flattened,  cuboidal,  swollen,  degenerated,  or  fatty.  The 
dilatation  of  the  tubes  may  reach  such  a  point  as  to  form  cysts 
of  some  size,  which  contain  fluid  or  coagulated  matter.  These 
cysts  follow  the  lines  of  systems  of  tubes,  or  are  situated  near 
the  capsules. 

Of  th.Q  glomeruli  a  certain  number  remain  of  normal  size,  but 
with  the  tuft  cells  swollen  or  multiplied.  Many  others  are 
found  in  all  stages  of  atrophy  and  of  change  into  connective  tis- 
sue. The  atrophy  seems  to  depend  partly  on  the  growth  of  tuft 
cells  and  intra-capillarv  ^cells,  partly  on  the  thickening  of  the 
capsules,  partly  on  the  occlusion  of  the  arteries.  If  the  chronic 
nephritis  follows  chronic  congestion  of  the  kidneys  the  glomeruli 
remain  large,  with  an  increased  growth  of  tuft  cells,  or  they  be- 
come atrophied,  but  with  the  dilatation  of  the  capillaries  still 
evident.  The  capillaries  of  the  glomeruli  may  be  the  seat  of 
waxy  degeneration.  The  arteries  exhibit  the  same  changes  as 
have  already  been  described  in  speaking  of  chronic  exudative 
nephritis. 


332  CHRONIC   NEPHRITIS   WITHOUT   EXUDATION. 


COMPLICATING    LESIONS. 

Heart. — Hypertrophy  of  the  left  ventricle  of  the  heart  is  fre- 
quently caused  by  exudative  nephritis,  but  much  more  frequently 
by  chronic  nephritis  without  exudation.  It  must  be  admitted, 
however,  that  such  an  hypertrophy,  although  frequent,  is  not 
constant,  that  with  both  exudative  and  non-exudative  nephritis 
there  may  be  no  change  in  the  wall  of  the  left  ventricle.  The 
hvpertrophy  of  the  wall  of  the  ventricle  may  after  a  time  be  suc- 
ceeded by  dilatation,  or  chronic  degeneration,  or  myocarditis. 

Chronic  endocarditis  is  often  associated  with  this  form  of 
nephritis,  apparently  both  lesions  being  produced  by  the  same 
causes.  It  may  also  happen  that  chronic  endocarditis  causes 
first  chronic  congestion  of  the  kidneys  and  then  chronic  nephri- 
tis without  exudation. 

Lungs. — Pulmonary  emphysema  and  cirrhosis  of  the  liver  are 
frequently  associated  with  chronic  nephritis. 

Arteries. — One  of  the  most  important  of  the  complicating 
lesions  is  chronic  endarteritis.  The  relationship  between  endar- 
teritis, or,  more  properly  speaking,  arteritis  and  nephritis,  and 
the  ways  in  which  they  are  associated  together,  are  not  as  fully 
understood  as  they  should  be.  The  principal  reason  for  this  is 
the  failure  to  recognize  the  fact  that  chronic  inflammation  of  the 
walls  of  the  arteries  is  just  as  much  a  disease  as  chronic  endocar- 
ditis, or  emphysema,  or  cirrhosis  of  the  liver. 

Arteritis. 

Unquestionably  arteritis  is  more  often  seen  associated  with 
other  diseases  than  by  itself.  It  must  also  be  admitted  that  it  is 
of  such  frequent  occurrence  in  old  persons  that  it  is  natural  to 
think  of  it  as  a  senile  change.  Still  farther,  the  use  of  such  names 
as  arterio-capillary  fibrosis  and  arterio-sclerosis  have  helped  to 
prevent  us  from  classing  arteritis  with  the  other  chronic  produc- 
tive inflammations. 

Chronic  inflammation  may  involve  the  entire  aortic  system,  of 
arteries,  or  it  may  be  confined  to  a  part  of  that  system. 

If  only  the  arteries  in  some  one  part  of  the  body  are  involved, 
then  in  that  part  of  the  body  the  blood-supply  is  irregular  or  cut 
off,  the  diseased  artery  may  become  dilated,  or  it  may  rupture. 

If  a  large  part  of  the   aortic   system   of  arteries  is   involved. 


CHRONIC   NEPHRITIS   WITHOUT   EXUDATION.  333 

then  the  patients  suffer  from  symptoms  which  seem  to  depend 
partly  upon  the  changes  in  the  arteries,  partly  upon  attacks  of 
contraction  of  the  arteries,  partly  upon  hypertrophy  of  the  left 
ventricle  of  the  heart  and  heart  failure,  partly  upon  the  obstruc- 
tion to  the  passage  of  blood  through  the  cerebral  arteries. 

The  clearest  idea  of  general  arteritis  as  a  disease  is  to  be  ob- 
tained by  observing  it  in  persons  not  over  forty  years  old  who 
have  no  complicating  lesions. 

At  first  for  a  number  of  years  these  patients  only  suffer  from 
impaired  nutrition,  a  disposition  to  become  anaemic,  and  attacks 
of  dyspnoea.  It  can  be  seen  and  felt  that  the  walls  of  the  tem- 
poral and  radial  arteries  are  thickened  and  that  the  left  ventricle 
of  the  heart  is  hypertrophied.  At  the  times  when  the  patient  has 
dyspnoea  the  tension  of  the  pulse  is  much  increased. 

For  a  considerable  length  of  time  the  nutrition  and  the  anae- 
mia can  be  improved  by  climate  and  by  diet.  The  attacks  of 
dyspnoea  can  be  controlled  by  the  drugs  which  dilate  the  arteries. 
But  sooner  or  later  the  patients  get  worse.  Some  of  them  get 
up  a  dyspnoea  that  cannot  be  controlled,  the  action  of  the  hyper- 
trophied heart  fails,  and  the  patients,  after  suffering  for  weeks 
or  months  with  the  most  distressing  symptoms,  die.  In  other 
cases  death  takes  place  with  cerebral  symptoms — sudden  vmcon- 
sciousness,  or  aphasia,  or  hemiplegia.  After  the  death  of  these 
patients  no  lesions  of  any  consequence  are  found  except  the 
changes  produced  by  chronic  inflammation  of  the  walls  of  the 
arteries. 

It  is  evident  that  the  symptoms  and  death  of  these  patients 
are  due  to  the  changes  in  the  arteries,  that  the  disease  from  which 
they  have  suffered  is  chronic  arteritis.  But  it  is  also  evident  that 
their  symptoms — loss  of  nutrition,  anaemia,  contraction  of  the 
arteries,  hypertrophy  of  the  left  venti-icle,  dyspnoea,  heart  failure, 
unconsciousness,  aphasia,  hemiplegia — are  also  the  symptoms  of 
chronic  nephritis. 

Still  further  we  find  that  many  patients  with  these  symptoms 
do  have  both  arteritis  and  nephritis.  In  any  given  case  with 
these  symptoms,  therefore,  it  is  a  matter  of  importance  to  deter- 
mine whether  the  patient  has  arteritis  alone,  or  nephritis  alone, 
or  both  diseases  at  the  same  time. 

Patients  who  have  chronic  nephritis  are  more  liable  than  are 
other  persons  to  attacks  of  pericarditis,  bronchitis,  and  gastric 
catarrh. 


334  CHRONIC   NEPHRITIS   WITHOUT   EXUDATION. 


SYMPTOMS. 

The  Urine. — The  typical  urine  of  chronic  non-exudative  ne- 
phritis is  a  urine  increased  in  quantity,  of  a  specific  gravity  of 
about  I. CIO,  containing  a  diminished  quantity  of  urea,  without 
albumin  or  casts,  or  with  a  trace  of  albumin  and  a  very  few  casts. 
But  exacerbations  of  the  nephritis  and  changes  in  the  circulation 
may  for  a  time  considerably  increase  the  quantity  of  albumin 
and  the  number  of  casts. 

Very  important  modifications  of  the  urine,  however,  are  of 
ordinary  occurrence.  It  is  quite  possible,  with  nephritis  of  this 
type  far  advanced,  to  have  urine  not  below  r.023  in  specific 
gravity  and  without  albumin  or  casts.  When  one  sees  this  urine 
during  life  and  then  the  kidneys  after  death,  it  is  difficult  to  un- 
derstand how  they  can  belong  to  each  other. 

On  the  other  hand,  there  are  cases  in  which  the  specific  gravity 
of  the  urine  falls  almost  to  i.ooo,  either  with  or  without  waxy 
degeneration  of  the  blood-vessels.  In  some  cases  the  quantity 
of  urine  is  very  much  increased — several  quarts  in  the  twenty- 
four  hours.  During  the  attacks  of  contraction  of  the  arteries, 
to  which  these  patients  are  liable,  the  urine  may  be  diminished 
to  a  few  ounces  or  even  suppressed. 

Cerebral  Symptoms. — In  a  great  many  of  the  cases  cerebral 
symptoms  are  developed  at  some  time  in  the  course  of  the  dis- 
ease. Headache  and  sleeplessness  are  often  present,  the  head- 
ache sometimes  so  severe  and  continuous  that  the  patient  is 
nearly  maniacal.  Instead  of  the  headache  there  may  be  neural- 
gic pains  in  different  parts  of  the  body. 

Muscular  twitchings  and  general  convulsions  are  much  more 
serious.  They  may  be  early  symptoms,  or  not  occur  until  late 
in  the  disease. 

Hehniplegia,  with  or  without  aphasia,  may  be  the  first  symp- 
tom to  call  attention  to  the  nephritis,  or  may  not  occur  until  later 
in  the  disease.  The  invasion  of  the  hemiplegia  is  sudden  and  is 
usually  accompanied  by  coma.  There  is  loss  of  motion  alone,  or 
of  both  motion  and  sensation.  The  hemiplegia,  aphasia,  and 
coma  may  continue  up  to  the  time  of  the  patient's  death,  or  dis- 
appear after  a  few  hours  or  days.  In  the  latter  case  the  patient 
may  have  several  such  attacks.  These  attacks  have  been  ascribed 
to  localized  oedema  of  the  brain.     In  the  cases  which  I  have  seen 


CHRONIC   NEPHRITIS    WITHOUT   EXUDATION.  335 

there  were  no  changes  in  the  brain  tissue,  but  the  cerebral  arteries 
were  damaged  by  chronic  arteritis. 

Delirium,  mild  or  violent,  stupor,  and  coma  may  come  on  in 
sudden  attacks,  or  be  developed  slowly  and  gradually. 

When  these  cerebral  symptoms  come  on  in  attacks  the  pulse 
is  of  high  tension,  the  temperature  is  raised,  and  the  patients  are 
said  to  suffer  from  acute  uraemia.  Very  often  they  recover  from 
a  number  of  these  attacks.  In  the  fatal  attacks  the  pulse  often 
loses  its  tension  and  becomes  rapid  and  feeble  ;  the  patients  die 
comatose  with  a  feeble  heart. 

Instead  of  such  acute  attacks  of  cerebral  symptoms,  delirium 
and  stupor  may  come  on  gradually  in  persons  far  advanced  in 
their  nephritis.  The  temperature  is  then  apt  to  be  below  the  nor- 
mal and  the  pulse  is  rapid  and  feeble. 

Temporary  blindness,  neuro-retinitis,  or  nephritic  retinitis 
are  developed  in  a  moderate  number  of  the  patients. 

Chronic  bronchitis  and  emphysema  very  frequently  exist  and 
their  symptoms  often  form  a  large  part  of  the  clinical  history. 

Attention  has  already  been  called  to  the  large  share  that 
chronic  arteritis  may  have  in  the  production  of  some  of  the  renal 
symptoms. 

The  Heart. — The  left  ventricle  of  the  heart  regularly  becomes 
hypertrophied  after  the  nephritis  has  lasted  for  several  months. 
The  disposition  to  hypertrophy  is,  I  think,  rendered  greater  by 
repeated  attacks  of  contraction  of  the  arteries  and  by  complicat- 
ing arteritis.  The  hypertrophy  is  usually  easily  made  out.  The 
patient  remains  unconscious  of  its  existence,  or  has  disturbances 
of  sensation  and  palpitation.  As  the  disease  goes  on  the  hyper- 
trophied heart  may  become  feeble,  and  then  dyspnoea  and  the 
other  evidences  of  feeble  circulation  make  their  appearance. 

In  the  same  way  the  complicating  endocarditis,  which  so 
often  exists,  may  give  no  trouble  until  the  valves  are  a  good  deal 
changed,  or  the  ventricles  dilated,  or  the  heart's  action  altered, 
or  the  arteries  contracted  ;  then  the  circulation  is  interfered  with, 
and  the  results  of  venous  congestion  of  different  parts  of  the 
body  show  themselves. 

Dyspnoea  is  a  frequent  symptom,  often  the  first  symptom  no- 
ticed by  the  patient.  It  is  a  spasmodic  dyspnoea  coming  on  in 
attacks,  which  last  for  minutes,  hours,  or  days.  It  is  made  worse 
by  bodily  or  mental  exertion,  or  by  the  recumbent  position.  It 
does  not  resemble  bronchial  asthma.     It  is  apparently  due  to  the 


336  CHRONIC   NEPHRITIS   WITHOUT   EXUDATION. 

association  of  changes  in  the  arteries  and  heart.  It  cannot  be 
distinguished  from  the  dyspnoea  which  is  caused  by  arteritis  with- 
out nephritis.  With  contraction  of  the  arteries  alone,  or  with  a 
feeble  heart  alone,  no  dyspnoea  may  exist  ;  but  if  the  contraction 
of  the  arteries  be  so  great  that  the  hypertrophied  heart  cannot 
overcome  the  obstruction,  or  if  with  contraction  of  the  arteries 
the  heart  becomes  dilated  or  feeble,  then  the  attacks  of  dysp- 
noea begin.  At  first  the  attacks  are  not  severe  and  are  of  short 
duration,  but  if  the  mechanical  conditions  which  cause  them  can- 
not be  controlled,  they  become  longer  and  more  distressing. 

The  sto7nach  may  continue  to  perform  its  functions  fairly  well, 
but  more  often  there  is  gastric  indigestion,  gastric  catarrh,  or 
spasmodic  vomiting. 

Dropsy  as  a  rule  is  absent  with  non-exudative  nephritis,  unless 
it  is  complicated  by  chronic  endocarditis,  by  cirrhosis  of  the  liver, 
or  by  the  disturbances  of  circulation  which  come  on  later  in  the 
nephritis. 

Profuse  bleeding  from  the  pelvis  of  atrophied  kidneys  is 
sometimes  seen.  In  all  cases,  after  a  time,  the  nephritis  exerts 
its  effects  upon  the  nutrition  of  the  patient,  and  the  ffesh  and 
strength  are  diminished.  On  the  other  hand,  the  patients  do 
not  usually  become  as  pale  as  they  do  with  an  exudative  ne- 
phritis. 

COURSE    OF    THE    DISEASE. 

It  is  characteristic  of  the  chronic  productive  inflammations  of 
the  lungs,  the  heart,  the  arteries,  the  liver,  and  the  kidneys  that, 
while  they  often  exist  as  serious  and  fatal  diseases,  they  may  also 
exist  as  lesions  and  yet  do  not  interfere  with  long  life  and  ap- 
parent good  health.  This  seems  to  depend,  at  least  in  part,  on 
the  rapidity  with  which  the  inflammatory  changes  in  these  dif- 
ferent parts  of  the  body  are  developed.  If  the  development  is 
slow  enough,  the  functions  of  the  organ  continue  to  be  per- 
formed in  spite  of  the  new  growth  of  connective  tissue. 

We  have  to  admit  that  in  all  cases  of  chronic  non-exudative 
nephritis  a  period  of  weeks,  or  months,  or  years  elapses  during 
which  the  changes  in  the  kidney  are  slowly  going  on,  and  yet  the 
patients  seem  well  and  are  not  aware  that  they  have  any  disease. 
How  far  the  nephritis  can  advance  and  how  many  years  it  can 
exist  before  the  symptoms  of  it  appear,  it  is  difficult  to  say.  We 
see  a  great  many  different  stages  in  the  development  of  the  ne- 


CHRONIC   NEPHRITIS    WITHOUT   EXUDATION.  33/ 

phritis  in  persons  who  die  from  other  diseases  and  have  never 
given  any  renal  symptoms. 

The  nephritis  is  of  slow  development,  gradually  altering  the 
structure  of  the  kidney  more  and  more,  so  that  we  should  expect 
that  the  symptoms  of  the  nephritis  would  also  be  developed  gradu- 
ally. This  is  very  often  the  case,  but  quite  as  often  the  nephritis 
will  advance  without  symptoms  up  to  a  certain  point  and  then 
the  patient  suddenly  becomes  ill. 

A.  Cases  with  Slow  Development  of  Symptoms. — Of  the  patients 
in  whom  the  symptoms  are  gradually  developed  we  may  dis- 
tinguish : 

1.  Patients  who  gradually  develop  hypertrophy  of  the  left 
ventricle  of  the  heart,  with  a  lowering  of  the  specific  gravity  of 
the  urine,  and  a  pulse  that  is  easily  made  too  tense  ;  otherwise 
their  health  is  good.  We  often  watch  these  persons  for  many 
years,  expecting  other  renal  symptoms.  But  the  symptoms  do 
not  come,  and  the  patients  die  of  some  other  disease. 

2.  Patients  who  have  digestive  disturbances,  and  gradual  loss 
of  flesh  and  strength.  The  urine  is  of  low  specific  gravity  and  in- 
creased quantity,  or  the  specific  gravity  and  quantity  remain 
almost  normal  ;  often  from  time  to  time  there  are  traces  of  albu- 
min and  a  few  hyaline  casts.  These  patients  are  often  very 
puzzling.  From  year  to  year  they  slowly  get  more  feeble  and 
more  emaciated  ;  the  digestive  disturbances  are  sometimes  better 
and  sometimes  worse.  Occasionally  there  is  an  interval  of  great 
improvement,  so  that  the  patients  think  they  have  entirely  re- 
covered. As  the  disease  lasts  a  long  time  the  patients  are  apt  to 
see  a  number  of  physicians  and  get  a  number  of  opinions,  for  the 
diagnosis  is  really  a  difficult  one.  Some  of  the  patients  die  from 
intercurrent  diseases,  but  others  go  on  and  die  simply  exhausted 
with  nothing  but  the  chronic  nephritis. 

3.  Patients  who  for  months  or  years  have  attacks  of  spas- 
modic dyspnoea,  and  between  these  attacks  are  comparatively 
well.  The  patients  are  usually  over  forty  years  of  age.  The 
attacks  of  dyspnoea  are  apt  to  come  on  in  the  early  morning  and 
go  off  later  in  the  day.  Often  chronic  arteritis,  or  chronic  en- 
docarditis, exists  at  the  same  time.  For  a  while  the  attacks  of 
dyspnoea  can  be  relieved,  and  the  patients  are  capable  of  mental 
and  physical  exertion  and  feel  quite  confident  of  recovery.  But 
as  the  attacks  of  dyspnoea  recur  they  last  longer  and  are  harder 
to  relieve.     Finally  comes  the  time  when  the  dyspnoea  cannot  be 


338  ■  CHRONIC   NEPHRITIS   WITHOUT   EXUDATION. 

relieved.  It  lasts  day  and  night  the  patients  cannot  lie  down, 
the  scrotum  and  legs  become  oedematous,  and  death  hardly  comes 
soon  enough  to  relieve  their  distress. 

4.  Patients  who  have  symptoms  progressing  for  several  years. 
At  first  vomiting,  or  headache,  or  neuralgic  pains.  Then  dysp- 
noea, a  little  dropsy  of  the  legs,  and  loss  of  fiesh  and  strength. 
Finally  death  from  exhaustion,  or  with  an  attack  of  convulsions, 
or  in  coma. 

5.  Patients  in  whom  the  symptoms  come  on  in  attacks,  each 
attack  worse  than  the  preceding,  and  the  general  health  more 
and  more  impaired  between  the  attacks.  During  the  attacks 
there  are  headache,  sleeplessness,  delirium,  stupor,  coma,  con- 
vulsions, dyspnoea,  vomiting — sometimes  one,  sometimes  another 
the  prominent  symptom.  The  tension  of  the  pulse  is  consider- 
ably increased.  The  urine  is  of  low  specific  gravity  and  often 
contains  a  little  albumin.  Between  the  attacks  the  patients  at 
first  seem  to  be  fairly  well,  but  later  they  gradually  lose  flesh  and 
strength.  The  urine  between  the  attacks  is  of  low  specific  grav- 
ity and  contains  little  or  no  albumin.  The  patients  finally  die  in 
one  of  the  attacks. 

B.  Cases  with  Rapid  Development  of  Symptoms. — Of  the  patients 
who  are  apparently  in  their  ordinary  health  until  there  is  a  vio- 
lent invasion  of  symptoms,  we  may  distinguish  those  in  whom  the 
attack  seems  to  be  precipitated  by  an  injury  or  an  intercurrent 
disease,  and  those  in  whom  it  comes  on  without  discoverable 
cause.  In  either  case  the  attack  regularly  takes  the  form  of  cere- 
bral symptoms,  or  of  dyspnoea,  or  of  vomiting,  or  of  sudden 
death.  During  these  attacks  the  tension  of  the  pulse  is  high, 
the  urine  is  diminished  in  quantity  or  suppressed  and  often  con- 
tains a  little  albumin. 

I.  The  cerebral  symptoms  are  general  convulsions,  coma, 
hemiplegia,  and  aphasia.  The  convulsions  come  on  suddenly  ; 
they  are  repeated  several  times ;  between  them  the  patients  are 
unconscious.  Many  of  the  patients  die  with  the  convulsions,  but 
a  few  recover.  We  are  apt  to  see  these  persons  for  the  first  time 
while  the  convulsions  are  going  on,  and  are  told  by  their  friends 
that  they  were  in  their  ordinary  health  until  the  convulsions 
began. 

The  coma  is  developed  in  the  same  rapid  way.  The  patient 
is  found  in  bed,  in  a  room,  or  in  the  street,  at  first  stupid  and 
muttering  incoherently,   then  completely  comatose.     From  this 


CHRONIC   NEPHRITIS   WITHOUT   EXUDATION.  339 

coma  they  do  not  emerge,  but  go  on  and  die  in  a  few  hours  or 
days. 

The  hemiplegia  is  like  that  with  a  clot  or  with  an  obstructed 
artery.  The  patient  falls  to  the  ground  unconscious  and  hemi- 
plegic.  If  the  hemiplegia  is  on  the  right  side  there  is  usually 
aphasia.  The  paralyzed  side  of  the  body  ma)'-  remain  quiet,  or 
become  rigid,  or  be  moved  involuntarily.  The  hemiplegia  and 
unconsciousness  usually  continue  up  to  death.  But  occasionally 
we  see  a  patient  who  recovers  both  motion  and  consciousness. 

2.  The  dyspnoea  often  starts  with  an  ordinary  bronchitis.  The 
patients  cannot  lie  down,  they  suffer  from  the  constant  feeling  of 
dyspnoea,  the  pulse  is  full  and  tense,  the  drugs  which  usually 
dilate  the  arteries  are  of  little  or  no  effect,  the  scrotum  and  legs 
become  oedematous.     The  patients  only  live  a  few  weeks. 

3.  The  vomiting  may  at  first  resemble  that  of  acute  gastritis, 
or  that  caused  by  some  irritating  substance  in  the  stomach.  But 
it  continues,  it  is  exhausting,  it  does  not  yield  to  the  ordinary 
remedies  directed  to  the  stomach  ;  the  pulse  is  full  and  tense. 
Such  vomiting,  however,  can  often  be  stopped  by  the  drugs  which 
dilate  the  arteries. 

4.  The  patients  after  an  injury,  or  a  surgical  operation,  or 
without  discoverable  cause  become  feeble,  the  heart's  action  is 
feeble,  the  urine  is  diminished  or  suppressed,  and  in  a  few  hours 
the  patient  is  dead.  These  cases  are  not  common.  They  are 
very  disagreeable  for  the  physician,  as  the  patients  seem  to  die 
without  sufficient  cause. 

TREATMENT. 

The  progress  of  the  nephritis  can  be  favorably  affected  by  at- 
tention to  the  diet  and  mode  of  life,  and  to  climate.  As  regards 
the  diet,  the  quantity  of  sugars  and  starches  taken  should  be  re- 
stricted, and  the  ingestion  of  fats  encouraged.  The  use  of  wine, 
spirits,  and  tobacco  should  be  discontinued.  Exercise  in  the 
open  air  is  to  be  advised  as  long  as  the  strength  permits  of  it. 
As  regards  climate,  we  must  consult  the  idiosyncrasy  of  the 
patient ;  it  should  be  a  climate  where  he  eats  well,  sleeps  well, 
and  feels  well.  There  is  a  decided  advantage  in  not  remaining 
in  the  same  place  throughout  the  year. 

In  the  patients  belonging  to  group  one,  with  urine  of  low- 
specific  gravity  and  hypertrophy  of  the  left  ventricle,  it  will  be 


340  CHRONIC   NEPHRITIS   WITHOUT   EXUDATION. 

found  that  whenever  the  tension  of  the  pulse  is  increased  the 
patients  do  not  feel  quite  so  well.  When  this  is  the  case  potas- 
sium iodide  will  often  soften  the  pulse  and  remove  the  discom- 
forts. These  patients  can  also  be  much  improved  by  regulated 
exercise  in  the  open  air. 

In  the  patients  belonging  to  group  two  the  treatment  is  di- 
rected to  the  digestive  disturbances  and  the  nutrition.  The  regu- 
lation of  the  diet  and  the  mode  of  life,  lavage  of  the  stomach,  re- 
lieving constipation,  and  increasing  the  production  of  bile  are  all 
of  importance.  When  the  production  of  urine  is  largely  in  ex- 
cess of  the  normal,  combinations  of  nux  vomica  and  sodium 
bromide  will  sometimes  act  as  a  specific  in  reducing  this  undue 
quantity. 

In  the  patients  with  attacks  of  spasmodic  dyspnoea  much  can 
be  done  with  the  drugs  which  dilate  the  arteries  and  stimulate 
the  heart.  According  to  the  tension  of  the  pulse  and  the 
strength  of  the  heart's  action,  we  use  these  drugs  separately  or 
together.  Chloral  hydrate,  nitro-glycerin,  and  potassium  iodide 
are  the  most  reliable  of  the  arterial  dilators  ;  digitalis,  strophan- 
thus,  and  caffeine  are  the  best  cardiac  stimulants  for  this  pur- 
pose. 

Tlie  treatment  of  the  attacks  of  headache,  convulsions,  coma, 
hemiplegia,  and  vomiting  is  a  matter  of  importance.  The  only 
working  theory  that  one  can  go  on  is  to  believe  that  at  the  time  of 
these  attacks  there  is  an  irritant  poison  in  the  blood  which  causes 
contraction  of  the  arteries,  and  that  the  cerebral  symptoms  are 
due  partly  to  the  contraction  of  the  arteries  and  partly  to  the 
poison  itself.  What  the  poison  is  or  whether  it  is  in  all  cases  the 
same  poison  we  do  not  know. 

Evidently  the  indications  given  for  treatment  by  this  theory 
are,  first,  to  remove  the  poison  from  the  blood  and,  second,  to 
dilate  the  contracted  arteries. 

The  plans  which  are  ordinarily  used  to  remove  the  poison  from 
the  blood  are  general  blood-letting,  purging,  sweating,  and 
diuresis.  These  measures  unquestionably  can  do  much  good. 
Whether  they  do  so  because  they  remove  poison  from  the  blood, 
or  because  they  relieve  the  arterial  tension,  is  a  matter  open  for 
discussion. 

Dilatation  of  the  arteries  can  be  effected  by  hypodermic  in- 
jections of  morphine ;  by  nitro-glycerin,  chloral  hydrate,  and 
potassium  iodide  ;  and  by  sweating.     Very  often  with  these  reme- 


PUERPERAL   ECLAMPSIA.  341 

dies  the  pulse  will  become  soft  and  the  cerebral  symptoms  will 
disappear.  But  after  the  nephritis  has  advanced  beyond  a  cer- 
tain point  it  is  found  that  all  these  remedies  are  inert ;  the  ten- 
sion of  the  pulse  and  the  cerebral  symptoms  continue.  Or,  in- 
stead of  this,  the  pulse  loses  its  tension,  becomes  rapid  and  fee- 
ble, the  cerebral  symptoms  continue,  and  the  patients  die. 

Puerperal  Eclampsia. 

During  the  later  months  of  pregnancy,  during  labor,  and  im- 
mediately after  childbirth,  women  not  infrequently  become 
anaemic  and  dropsical,  have  albumin  in  the  urine,  and  develop 
alarming  cerebral  symptoms  :  headache,  blindness,  convulsions, 
and  coma. 

These  symptoms  are  especially  frequent  in  primiparae,  in  young 
women,  and  with  twin  pregnancies.  They  may  be  repeated  in 
several  successive  pregnancies.  They  belong  to  the  second  half 
of  pregnancy,  increase  in  severity  as  the  pregnancy  advances,  and 
are  at  their  worst  during  labor. 

MORBID    ANATOMY. 

In  women  dying  with  cerebral  symptoms  and  albuminuria  at 
about  the  time  of  childbirth,  I  have  found  the  kidneys  in  the  fol- 
lowing conditions  : 

Normal  kidneys. 

Dilatation  of  the  pelves  and  ureters. 

Acute  degeneration  of  the  kidney. 

Acute  exudative  nephritis. 

Acute  productive  nephritis. 

Chronic  nephritis. 

In  some  of  the  patients,  even  in  young  women,  I  have  found 
well-marked  disease  of  the  cerebral  arteries. 

ETIOLOGY. 

A  number  of  theories  have  been  entertained  as  to  the  causes 
of  puerperal  eclampsia.  It  must  be  confessed  that  no  one  of  them 
is  satisfactory,  and  that  the  subject  is  still  obscure.  The  ordi- 
nary explanations  are  as  follows  : 

I.   Pressure  on  the  renal  veins  by  the  gravid  uterus  produces 


342  PUERPERAL   ECLAMPSIA. 

a  chronic  congestion  of  the  kidneys,  which  interferes  with  their 
functions. 

2.  Pressure  of  the  uterus  on  the  ureters  renders  it  necessary 
for  the  kidneys  to  secrete  against  a  higher  pressure,  so  that  they 
are  unable  to  get  rid  of  the  proper  quantity  of  excrementitious 
substances. 

3.  The  kidneys  are  obliged  to  excrete  waste  products  not  only 
from  the  mother,  but  also  from  the  enlarged  uterus  and  the 
foetus,  and  this  extra  work  they  are  unable  to  perform. 

4.  It  has  been  demonstrated  in  some  cases  that  before  the  con- 
vulsions there  is  a  diminished  quantity  of  excrementitious  prod- 
ucts in  the  urine,  and  after  the  cessation  of  the  convulsions  an 
increase  of  these  products  ;  therefore  the  convulsions  are  due  to 
the  retention  of  these  excrementitious  substances  in  the  blood. 

5.  That  for  some  reason  the  patients  have  cerebro-spinal  con- 
gestion. 

6.  That  for  some  reason  they  have  cerebro-spinal  anaemia. 

7.  That  the  convulsions  are  of  the  nature  of  acute  epileptic 
attacks  due  to  irritation  of  nerves  in  the  pelvis. 

8.  That  the  enlarged  uterus  acts  as  an  irritant  to  the  vaso- 
motor nerves  and  so  causes  a  contraction  of  the  arteries  through- 
out the  body. 

9.  That  the  enlarged  uterus  causes  irritation  of  the  vaso-motor 
nerves  which  supply  the  renal  arteries  ;  the  contraction  of  the 
renal  arteries  causes  death  or  degeneration  of  the  renal  epithe- 
lium ;  the  changes  in  the  renal  epithelium  render  the  kidneys 
unable  to  excrete  poisonous  substances  ;  the  accumulation  of 
these  substances  in  the  blood  causes  the  convulsions,  etc. 

10.  There  is  at  the  time  of  childbirth  in  some  women  a  toxic 
substance  produced  in  some  unknown  way,  which  is  not  caused 
by  any  change  in  the  function  of  the  kidneys,  but  which  is 
capable  of  causing  transudation  of  serum  from  the  vessels,  con- 
traction of  the  arteries,  acute  degeneration  of  the  kidneys,  and 
acute  nephritis.  In  other  words,  the  changes  in  the  kidneys  are 
not  the  cause  of  the  convulsions,  etc.,  but  they  are  the  result  of 
the  same  poison  which  produces  the  albuminuria  and  the  cere- 
bral symptoms. 

SYMPTOMS. 

(i)  There  are  a  considerable  number  of  pregnant  women  in 
whose  urine  during  the  latter  months  of  pregnancy  albumin  is 


PUERPERAL    ECLAMPSIA.  343 

present  in  appreciable  quantities  ;  tliey  have  no  otiier  symptoms 
and  pass  through  labor  without  trouble, 

(2)  There  are  women  who,  during  the  latter  months  of  preg- 
nancy, have  scanty  and  albuminous  urine,  more  or  less  dropsy  of 
the  legs,  and  become  pale  and  anaemic.  They  may  pass  through 
childbirth  safely  and  do  well  afterward,  but  some  of  them  have 
a  chronic  nephritis  dating  from  the  pregnancy, 

(3)  In  a  small  number  of  women  at  about  the  time  of  child- 
birth, either  before,  during,  or  after  labor,  there  are  cerebral 
symptoms.  In  some  of  these  women  albumin  has  been  present 
in  the  urine  during  the  pregnancy;  in  others,  besides  the  albu- 
minuria, dropsy  and  anaemia  have  also  been  present  ;  but  in 
others  the  cerebral  symptoms  are  suddenly  developed  without 
any  premonitory  conditions. 

The  cerebral  attacks  are  characterized  by  nausea  and  vomit- 
ing, headache,  blindness,  muscular  twitchings,  general  convul- 
sions, stupor,  coma,  hemiplegia,  a  rise  of  temperature,  a  pulse  of 
high  tension,  venous  congestion  of  the  skin,  the  urine  diminished 
in  quantity  or  suppressed,  usually  containing  large  quantities  of 
albumin.  The  cases  vary  as  to  how  many  of  these  symptoms  are 
present.  A  fair  proportion  of  the  patients  survive  these  attacks, 
although  the  children  usually  die.  In  the  fatal  cases  death  takes 
place  with  the  general  convulsions,  with  hemiplegia,  or  with 
coma. 

After  the  termination  of  the  labor  and  the  disappearance  of 
the  alarming  symptoms  the  anxieties  of  the  obstetrician  are  at 
an  end,  but  those  of  the  physician  begin.  For  in  many  of  these 
women  a  nephritis  originates  during  pregnancy,  which  continues 
afterward  as  a  chronic  inflammation  and  ultimately  destroys  life. 

TREATMENT. 

While  there  have  been  many  different  opinions  as  to  the 
nature  of  puerperal  eclampsia,  there  is  a  good  deal  of  unifor- 
mity as  to  the  treatment.  If  the  convulsions  come  on  at  about 
the  end  of  pregnancy,  it  is  generally  agreed  that  labor  should 
be  brought  on  and  the  child  delivered  as  soon  as  possible. 
Apart  from  this  we  try  to  unload  the  veins  and  dilate  the  arteries. 
This  can  be  done  by  general  blood-letting  and  by  the  use  of 
nitro-glycerin,  chloral  hydrate,  and  opium.  In  order  to  guard 
against  the  cerebral  symptoms  it  is  of  more  practical  importance 


344  SUPPURATIVE   NEPHRITIS. 

to  watch  the   arteries  and  the   heart  than   to  test  the  urine  for 
albumin. 

Suppurative  Nephritis. 

Suppurative  inflammation  of  the  pelvis  of  the  kidney  and  of 
the  kidney  itself  occurs  under  several  different  conditions.  It 
is  the  result  of  injuries  ;  it  is  due  to  emboli  ;  it  occurs  without 
discoverable  cause  ;  it  is  secondary  to  cystitis,  the  cystitis  being 
due  to  stricture  of  the  urethra,  to  stone  in  the  bladder,  to 
paraplegia,  to  operations  on  the  urethra,  bladder,  and  uterus, 
to  gonorrhoea,  or  to  enlarged  prostate.  Chronic  suppurative 
pyelo-nephritis  may  be  caused  by  the  presence  of  calculi  in  the 
pelvis  of  the  kidney. 

I.    SUPPURATIVE    NEPHRITIS    FROM    INJURY. 

Gunshot  wounds,  incised  or  punctured  wounds,  falls,  blows, 
and  kicks  are  the  ordinary  traumatic  causes.  If  the  injury  be 
a  very  severe  one,  it  causes  the  death  of  the  patient  in  a  short 
time  ;  if  it  be  less  severe,  suppurative  inflammation  may  be 
developed. 

The  inflammatory  process  may  be  diffuse,  so  that  the  whole 
of  one  or  both  kidneys  is  converted  into  a  soft  mass  composed 
of  pus,  blood,  and  broken-down  tissue  ;  or  it  is  circumscribed, 
and  one  or  more  abscesses  are  found  in  the  kidney,  which  may 
communicate  with  its  pelvis. 

Symptoms. — Rigors  mark  the  beginning  of  the  suppuration 
and  are  often  repeated  throughout  its  course.  A  febrile  move- 
ment is  developed,  which  is  apt  to  assume  the  hectic  character 
with  sweating.  There  is  often  vomiting.  There  may  be  very 
severe  pain  referred  to  the  region  of  the  inflamed  kidney. 
The  urine  is  diminished  or  suppressed  ;  it  contains  blood  alone, 
or  blood  and  pus.  In  the  bad  cases  the  patients  pass  into  the 
typhoid  state,  become  delirious,  and  die  comatose,  or  with  a 
rapid  and  feeble  pulse.  Or  the  disease  is  protracted,  the  pa- 
tients become  more  and  more  emaciated,  and  finally  die  ex- 
hausted. In  other  cases  the  symptoms  abate,  the  urine  returns 
to  its  natural  condition,  and  the  patients  recover. 

Treatjnent. — The  management  of  these  cases  is  rather  sur- 
gical than  medical.  The  external  wound  is  to  be  treated  an- 
tiseptically,  and  the  suppurating  kidney  is  to  be  incised  or 
removed,  as  may  be  necessary. 


SUPPURATIVE   NEPHRITIS.  345 


2.    ABSCESSES    PRODUCED    BY    EMBOLI. 

In  ordinary  endocarditis  with  vegetations  on  the  valves  it 
often  happens  that  fragments  of  the  vegetations  become  fixed 
in  the  branches  of  the  renal  artery.  When  this  is  the  case  white 
infarctions  are  produced. 

With  malignant  endocarditis  and  with  septic  infections  em- 
boli find  their  way  into  the  branches  of  the  renal  artery  and 
set  up  circumscribed  foci  of  suppurative  inflammation.  The 
kidneys  become  enlarged  and  are  studded  with  little  white  points 
surrounded  by  red  zones.  These  little  white  points  are  formed 
by  an  infiltration  of  pus-cells  between  the  tubes,  followed  by 
the  death  and  breaking  down  of  the  kidney  tissue.  The  bac- 
teria of  suppuration  are  found  in  these  little  abscesses. 

Sy?7iptoins. — These  embolic  abscesses  can  hardly  be  said  to 
have  a  clinical  history.  Whatever  symptoms  may  belong  to 
them  are  lost  in  those  of  the  general  disease  from  which  the 
patient  is  suffering, 

3.    IDIOPATHIC   ABSCESSES. 

These  occur  without  discoverable  cause.  Only  one  kidney 
is  involved.  We  find  after  death  part  of  the  kidney  destroyed  ; 
the  remaining  portions  contain  abscesses  ;  the  pelvis  is  dilated 
and  contains  pus,  the  capsules  are  thickened,  the  suppurative 
inflammation  may  extend  to  the  surrounding  tissues  so  that 
sinuses  are  formed,  and  even  perforations  into  the  intestine  or 
through  the  diaphragm.  It  is  very  difficult  in  these  cases  to  tell 
whether  the  inflammation  begins  in  the  kidney  or  in  its  pelvis. 

Symptoms. — The  symptoms  begin  gradually  and  are  for  some 
time  obscure.  There  are  repeated  chills  and  an  irregular  febrile 
movement.  The  patients  lose  flesh  and  strength,  become  anae- 
mic, and  are  often  troubled  by  nausea  and  vomiting.  There  is 
more  or  less  pain  over  the  inflamed  kidney.  After  a  time  the 
pelvis  of  the  kidney  may  be  so  much  dilated  as  to  form  a  tumor. 
If  the  pus  escapes  from  time  to  time  through  the  ureter,  this 
tumor  will  vary  in  size.  The  urine  at  intervals  contains  pus  and 
fragments  of  broken-down  kidney  tissue.  If  the  suppuration 
extends,  there  will  be  sinuses  running  behind  the  peritoneum, 
or  into  the  colon,  or  upward  through  the  diaphragm.  The  dis- 
ease is   apt  to  last  a  long  time.     The  patients  are  liable  to  have 


346  SUPPURATIVE   NEPHRITIS. 

chronic  nephritis  of  the   other  kidney,  or  waxy  degeneration  of 
the  viscera. 

Treat?nent. — Tlie  only  plan  of  treatment  is  to  cut  down  on 
the  suppurating  kidney  and  treat  it  as  an  abscess,  or  to  remove 
it  altoarether. 


4.    SUPPURATIVE    PYELO-NEPHRITIS    WITH    CYSTITIS. 

Both  kidneys  become  inflamed.  The  pelves  are  congested 
and  coated  with  pus  or  fibrin.  The  kidneys  are  swollen,  con- 
gested, and  studded  with  foci  of  pus.  The  smallest  foci  are  not 
visible  to  the  naked  eye,  but  with  the  microscope  we  find  collec- 
tion of  pus-cells  between  the  tubes,  with  swelling  and  degenera- 
tion of  the  epithelium  within  the  tubes.  The  larger  purulent 
foci  look  like  white  streaks  'or  wedges  running  parallel  to  the 
tubes  and  surrounded  by  zones  of  congestion.  The  larger  ab- 
scesses replace  considerable  portions  of  the  kidneys. 

The  ureters  in  some  cases  are  inflamed,  their  walls  thickened, 
their  inner  surfaces  coated  with  pus  or  fibrin.  The  bladder  pre- 
sents the  lesions  of  acute  or  of  chronic  cystitis. 

Etiology. — This  form  of  nephritis  seems  to  be  always  second- 
ary to  a  cystitis,  the  infection  extending  from  the  bladder  through 
the  ureters  to  the  kidneys.  The  cases  of  cystitis  in  which  a  sup- 
purative nephritis  is  likely  to  be  developed  are  those  due  to 
strictures  of  the  urethra,  stone  in  the  bladder,  operations  on  the 
urethra,  bladder,  and  uterus,  paraplegia,  gonorrhoea,  and  en- 
larged prostate. 

Symptoms. — When  the  nephritis  occurs  with  cystitis  due  to 
stone  in  the  bladder,  strictures  of  the  urethra,  or  operations  on 
the  genito-urinary  tract,  the  symptoms  are  much  the  same.  The 
patient  has  first  the  symptoms  belonging  to  the  cystitis,  then 
he  is  attacked  with  chills  and  a  rise  of  temperature.  The  chills 
are  repeated,  the  temperature  is  irregular  and  accompanied  by 
profuse  sweating.  There  is  a  rapid  change  in  the  general  condi- 
tion of  the  patient,  he  becomes  more  prostrated  and  emaciated 
from  day  to  day.  The  face  is  drawn  and  anxious,  the  tongue  dry 
and  brown,  the  pulse  rapid  and  feeble  ;  delirium  is  developed, 
and  the  patient  finally  dies  in  the  septic  condition.  The  urine  is 
diminished  in  quantity  or  suppressed  ;  it  contains  blood,  pus, 
and  mucus  derived  partly  from  the  bladder,  partly  from  the  kid- 
neys. 


TUBERCULAR   NEPHRITIS.  347 

Cases  of  suppurative  nephritis  due  to  a  gonorrlioeal  cystitis 
are  not  common,  but  several  of  them  have  been  observed.  Mur- 
chison  describes  two  cases,  in  both  of  which  the  cerebral  symp- 
toms were  very  marked — delirium,  convulsions,  and  coma.  I 
have  seen  one  such  case.  The  patient  was  a  prostitute  who  came 
into  the  hospital  with  a  specific  vaginitis.  After  a  few  days  she 
developed  the  symptoms  of  an  acute  cystitis  ;  then,  after  a  few 
more  days,  she  was  attacked  with  chills  and  a  rise  of  temperature, 
passed  rapidly  into  the  septic  condition,  and  died.  At  the  au- 
topsy there  were  found  acute  cystitis,  pyelitis,  and  numerous 
small  abscesses  in  both  kidneys. 

When  suppurative  nephritis  complicates  the  cystitis  due  to 
enlarged  prostate,  the  symptoms  are  somewhat  different.  The 
patients  are  usually  men  over  fifty  years  old.  They  have  gener- 
ally suffered  from  the  symptoms  of  enlarged  prostate,  retention  of 
urine  either  constant  or  intermittent,  and  more  or  less  cystitis 
with  pus  and  mucus  in  the  urine.  Sometimes,  however,  no  such 
history  is  obtained  ;  the  patients  assert  that  they  have  had  no  pre- 
vious bladder  trouble.  The  first  symptom  is  a  diminution  in  the 
quantity  of  urine,  with  the  appearance  of  blood  mixed  with  it,  or 
the  urine  may  be  suppressed  altogether.  The  blood  may  be  pres- 
ent in  considerable  quantities,  so  that  the  patients  seem  to  pass 
blood  instead  of  urine.  The  patients  rapidly  become  prostrated 
and  very  anxious.  There  are  usually  no  chills,  and  there  may  be 
no  rise  in  temperature.  The  prostration  becomes  more  marked, 
the  pulse  is  rapid  and  feeble,  the  skin  is  cold  and  bathed  in  per- 
spiration, and  the  patients  die  in  collapse  at  the  end  of  a  few  days. 
Or,  instead  of  such  a  history,  the  patients  may  behave  as  if  they 
were  the  subjects  of  septic  poisoning. 

Prognosis. — Suppurative  nephritis  secondary  to  cystitis  is  a 
very  fatal  disease  ;  so  far  as  I  know  all  the  patients  die. 

Treatment. — The  treatment  for  these  cases  is  altogether  a  pre- 
ventive one  directed  to  the  cystitis.  When  the  nephritis  is  once 
established  we  have  no  further  control  over  the  case. 

Tubercular  Nephritis. 

The  different  portions  of  the  genito-urinary  tract — the  kid- 
neys, ureters,  bladder,  seminal  vesicles,  prostate,  testicle,  uterus, 
Fallopian  tubes,  and  ovaries — may  become  the  seat  of  a  localized 
tubercular  inflammation. 


348  TUBERCULAR   NEPHRITIS. 

Such  an  inflammation  may  involve  one  of  these  organs,  or 
several  of  them.  If  several  of  them  are  involved,  they  are  on  the 
same  side  of  the  body,  usually  the  left  side.  The  inflammation 
is  attended  with  the  growth  of  tubercle  bacilli  and  the  formation 
of  tubercle  tissue.  The  tubercle  tissue  soon  dies  and  undergoes 
cheesy  degeneration. 

In  the  kidneys  the  inflammation  begins  in  the  mucous  mem- 
brane of  the  pelvis  and  calyces,  and  extends  to  the  parenchyma, 
until  a  large  part  of  the  kidney  is  replaced  by  the  degenerated 
new  tissue.  The  cheesy  taasses  may  soften  or  become  calcified, 
while  the  kidney  tissue  between  them  is  converted  into  fibrous 
tissue  more  or  less  infiltrated  with  pus. 

The  other  kidney,  after  a  time,  is  apt  to  become  the  seat  of 
the  exudative  form  of  chronic  nephritis  with  waxy  degeneration 
of  the  blood-vessels. 

The  tubercular  nephritis  may  be  complicated  by  tubercular 
inflammation  of  other  parts  of  the  genito-urinary  tract  on  the 
same  side  of  the  body,  by  tubercular  peritonitis,  pulmonary  tu- 
berculosis, or  general  tuberculosis. 

The  disease  is  said  to  occur  at  all  ages  ;  it  is  most  frequent  in 
middle-aged  persons.  It  occurs  twice  as  often  in  men  as  in 
women. 

SYMPTOMS. 

The  urine  usually,  but  not  always,  contains  from  time  to  time 
blood,  pus,  detritus,  epithelium,  shreds  of  tissue,  and  tubercle 
bacilli.  When  the  other  kidney  has  become  the  seat  of  chronic 
nephritis  the  specific  gravity  of  the  urine  falls  and  albumin  and 
casts  are  present. 

Pain,  either  continuous  or  in  paroxysms,  and  tenderness  are 
aften  present  in  the  inflamed  kidney.  There  may  be  hectic  fever 
with  night  sweats  ;  the  patients  gradually  lose  flesh  and  strength. 
The  kidney  may  be  enlarged  so  as  to  form  a  tumor  which  can  be 
felt.  After  a  time  there  are  added  the  symptoms  of  tubercular 
inflammation  of  other  parts  of  the  genito-urinary  tracts,  of  tuber- 
cular peritonitis,  of  pulmonary  phthisis,  of  waxy  degeneration  of 
the  viscera,  or  of  chronic  nephritis  of  the  other  kidney. 

The  disease  lasts,  as  a  rule,  for  several  years.  Most  of  the 
cases  terminate  fatally,  but  it  is  possible  for  the  inflammation  to 
stop  and  for  the  patient  to  recover. 


NEW    GROWTHS.  349 


TREATMENT. 

The  proper  treatment  for  tubercular  nephritis  is  the  removal 
of  the  diseased  kidney.  The  practical  difficulty  is  to  make  the 
diagnosis  before  other  parts  of  the  genito-urinary  tract  have  be- 
come tubercular,  or  before  the  remaining  kidney  has  become  the 
seat  of  chronic  nephritis. 

We  may  hope  that  climate  and  feeding  may  have  the  same 
good  effects  on  tubercular  nephritis  as  they  have  on  pulmonary 
tuberculosis. 

New  Growths  of  the  Kidney. 

The  most  important  new  growths  of  the  kidney  are  those 
which  belong  to  the  classes  of  sarcoma  and  adenoma. 

The  sarcomata  grow  from  the  kidney  itself,  or  from  its  pelvis. 
They  are  composed  of  connective  tissue  with  an  excess  of  cells, 
with  which  may  be  mixed  mucous  tissue  or  muscular  tissue. 
These  tumors  often  reach  a  large  size  and  may  grow  for  a  num- 
ber of  years  before  they  cause  death.  They  form  a  hard  abdom- 
inal tumor  which  at  first  retains  the  position  and  shape  of  the 
kidney,  but  may  finally  become  so  large  as  to  occupy  a  consider- 
able part  of  the  abdominal  cavity. 

They  are  found  as  congenital  tumors,  are  rather  frequent  in 
infants  and  children,  and  are  occasionally  met  with  in  adults. 

The  adenomata  grow  in  the  cortex  of  the  kidney  in  the  form  of 
nodular  tumors.  They  may  follow  the  papillary  or  the  tubular 
type.  In  some  cases  the  tumor  or  tumors  never  attain  any  con- 
siderable size,  are  not  malignant,  and  give  rise  to  no  symptoms. 
In  other  cases  the  tumors  become  much  larger,  and  may  then 
behave  like  malignant  growths.  These  large  tumors  are  very 
vascular.  The  adenomata  which  run  a  malignant  course,  with 
the  formation  of  metastatic  tumors,  are  often  called  carcinomata. 

SYMPTOMS. 

The  sarcomata  and  adenomata,  so  far  as  their  symptoms  are 
concerned,  may  conveniently  be  described  together.  In  both  of 
them  there  are  four  principal  symptoms  :  a  tumor,  pain,  haema- 
turia,  and  loss  of  nutrition. 

The  tumor  is  appreciable  as  soon  as  it  has  reached  a  sufficient 


350  THE   CYSTIC   KIDNEY. 

size.  While  it  retains  tlie  natural  position  and  outlines  of  the 
kidney  the  diagnosis  is  comparatively  easy,  but  as  the  tumor  be- 
comes larger  and  adhesions  are  formed,  it  becomes  more  difficult 
to  distinguish  it  from  other  abdominal  tumors. 

Hsematuria  is  present  at  some  time  in  the  disease  in  about 
half  the  cases.  The  hemorrhages  may  be  very  large  with  rapid 
anaemia  and  exhaustion,  or  moderate  in  quantity,  or  so  little  as 
only  to  be  appreciable  with  the  microscope.  They  are  apt  to 
recur  at  intervals  of  days  or  weeks. 

The  pain  is  referred  to  the  situation  of  the  diseased  kidney. 
It  is  by  no  means  a  constant  symptom,  but  it  may  occur  early  and 
be  throughout  a  prominent  feature.  They  are  apt  to  come  on  in 
attacks  and  to  radiate  downward  along  the  course  of  the  ureter. 

Loss  of  appetite,  nausea  and  vomiting  are  troublesome  symp- 
toms in  some  of  the  patients. 

The  loss  of  flesh  surely  comes  sooner  or  later,  but  it  is  curious 
in  some  cases  how  long  the  general  health  may  remain  unaffected 
and  how  long  life  can  be  prolonged  even  with  enormous  tumors. 

TREATMENT. 

The  same  rule  seems  to  hold  good  for  these  tumors  in  the 
kidney  as  for  the  same  tumors  in  other  parts  of  the  body.  If  the 
kidney  be  removed  while  the  growth  is  still  small,  the  prognosis 
is  fairly  good.  If  it  be  not  removed  until  the  tumor  is  large  or 
until  metastatic  tumors  have  been  formed,  the  prognosis  is  bad. 

The  Cystic  Kidney. 

Cysts  are  formed  in  the  kidney  both  during  intra-uterine  and 
extra-uterine  life. 

The  congenital  cystic  kidney  is  a  very  remarkable  pathologi- 
cal condition.  Either  one  or  both  kidneys  are  enormously  en- 
larged and  converted  into  a  mass  of  cysts.  The  cysts  are  of  all 
sizes,  and  are  separated  from  each  other  by  fibrous  septa  or  com- 
pressed kidney  tissue.  They  contain  a  clear,  yellow,  acid  fluid, 
holding  in  solution  the  urinary  salts  ;  or  the  fluid  is  turbid 
and  brown,  and  contains  blood,  uric-acid  crystals,  and  cholester- 
ine.  The  cysts  are  lined  with  a  single  layer  of  flat  epithelial 
cells.  They  seem  to  be  formed  by  a  dilatation  of  the  tubules  and 
of  the  capsules  of  the  Malpighian  bodies.  As  causes  for  such  a 
dilatation  are  found  obliteration  of  the  tubes  in  the  papillae,  or 


PERINEPHRITIS.  35 1 

Stenosis  of  the   pelvis,  ureters,  bladder,  or   urethra.     Other  con- 
genital malformations  are  often  associated  with  this  one. 
In  adult  life  we  find  three  varieties  of  cystic  kidney  : 

1.  In  kidneys,  which  are  otherwise  normal,  there  are  one  or 
more  cysts  filled  with  clear  or  brown  serum,  or  colloid  matter. 
These  cysts  do  not  appear  to  interfere  at  all  with  the  functions 
of  the  kidneys. 

2.  In  chronic  diffuse  nephritis,  especially  in  the  atrophic 
form,  groups  of  tubes  are  dilated.  Apparently  one  or  more  of 
the  larger  tubes  in  the  pyramids  are  obstructed,  and  this  causes 
dilatation  of  a  corresponding  group  of  tubes.  Such  a  dilatation 
may  be  moderate  in  size,  or  it  may  form  cysts  visible  to  the 
naked  eye. 

3.  Both  kidneys  are  very  much  enlarged  and  converted  into 
a  mass  of  cysts  containing  clear  or  colored  serum,  or  colloid 
matter.  The  nature  of  these  cysts  is  uncertain.  It  is  possible 
that  they  are  congenital.  They  are  sometimes  associated  with 
similar  cysts  in  the  liver.  Their  clinical  history  resembles  that 
of  some  of  the  cases  of  chronic  diffuse  nephritis  without  exuda- 
tion. The  patients  go  on  for  a  long  time  without  symptoms, 
except  that  the  specific  gravity  of  the  urine  gradually  falls  and  a 
little  albumin  is  occasionally  present.  Finally  they  have  an 
attack  of  general  convulsions  or  of  coma,  and  die  in  a  short  time. 

Perinephritis. 

The  loose  connective  tissue  around  the  kidney  may  become 
the  seat  of  suppurative  inflammation,  and  in  this  way  abscesses  of 
considerable  size  may  be  formed. 

Etiology. — Perinephritis  is  either  secondary  or  primary.  The 
secondary  cases  are  due  to  extension  of  the  inflammation  from 
abscesses  in  the  vicinity,  such  as  are  formed  with  caries  of  the 
spine,  pelvic  cellulitis,  puerperal  parametritis,  perityphlitis,  sup- 
puration of  the  kidney,  and  pyelonephritis.  The  primary  cases 
occur  after  exposure  to  cold,  after  contusions  over  the  lumbar  re- 
gion, great  muscular  exertion,  and  without  discoverable  cause. 
The  lesion  is  said  to  complicate  typhus  and  typhoid  fever  and 
small-pox.  The  disease  occurs  both  in  children  and  adults  ;  most 
of  the  cases  reported  have  been  in  persons  between  the  ages  of 
twenty  and  forty  years. 

Morbid  Anatomy. — The  connective  tissue  behind   the   kidney 


352  PERINEPHRITIS. 

seems  to  be  the  usual  point  of  origin  of  the  inflammatory  pro- 
cess, and  it  is  here  that  the  pus  first  collects.  After  the  abscess 
has  reached  a  certain  size  the  suppuration  seems  to  have  a  natural 
tendency  to  spread,  and  the  pus  burrows  backward  through  the 
muscles  ;  downward  along  the  iliac  fossa,  even  as  far  as  the  peri- 
neum, scrotum,  or  vagina  ;  forward  into  the  peritoneal  cavity,  the 
colon,  or  the  bladder  ;  upward  through  the  diaphragm.  The  kid- 
ney is  compressed  by  the  abscess  or  becomes  involved  in  the  sup- 
purative process.  The  soft  parts  around  the  abscess  become 
thickened  and  indurated. 

Symptoms. — The  disease  begins,  as  a  rule,  with  pains  and  ten- 
derness referred  to  one  lumbar  region,  between  the  lower  border 
of  the  ribs  and  the  crest  of  the  ilium,  sometimes  to  a  point  above 
or.  below  this.  At  about  the  same  time  are  developed  repeated 
rigors,  a  febrile  movement  with  evening  exacerbations,  sweat- 
ing, loss  of  appetite,  vomiting,  and  prostration.  These  are  all 
the  symptoms  for  from  one  to  two  weeks.  Then  the  skin  over 
the  lumbar  region  on  one  side  becomes  red  and  oedematous,  the 
corresponding  thigh  is  kept  flexed  and  rigid,  for  any  movement 
of  it  gives  pain.  Then  the  lumbar  region  becomes  more  and 
more  swollen  until  fluctuation  can  be  made  out,  and  finally  the 
abscess  breaks  through  the  skin.  If  such  cases  are  left  to  run 
their  course  the  abscess  may  reach  a  very  large  size.  If  the  pus 
does  not  extend  backward,  but  in  some  other  direction,  the  symp- 
toms are  more  obscure,  for  the  local  symptoms  of  an  abscess  in 
the  back  are  absent. 

If  the  abscess  ruptures  into  the  peritoneal  cavity,  the  symp- 
toms of  acute  general  peritonitis  are  suddenly  developed.  If  it 
perforates  into  the  colon  or  bladder,  the  pus  is  discharged  with 
the  faeces  or  the  urine.  If  the  perforation  is  through  the  dia- 
phragm there  will  be  empyema,  or  the  lung  becomes  adherent 
and  pus  is  coughed  up  from  the  bronchi.  As  soon  as  the  ab- 
scess is  opened  and  the  pus  escapes,  the  acute  constitutional 
symptoms  subside. 

Trousseau  believes  that  the  inflammatory  process  sometimes 
stops  short  of  the  production  of  pus.  In  such  cases,  of  course, 
there  are  no  evidences  of  the  formation  of  an  abscess. 

If  the  abscess  ruptures  spontaneously  or  is  opened  by  the 
surgeon,  the  patient  is  likely  to  recover,  but  the  suppurative  pro- 
cess may  continue  and  the  patient  die  exhausted,  usually  with 
waxv  viscera. 


HYDRONEPHROSIS.  353 

Perforation  into  the  peritoneum,  the  pleura,  or  the  lung 
causes  death. 

Treatment. — The  main  point  in  the  treatment  is  to  discover 
the  abscess  and  to  open  it.  The  longer  the  suppuration  goes  on 
and  the  larger  the  abscess,  so  much  the  worse  is  the  prognosis. 
It  is  proper  to  explore  with  the  aspirator  after  the  disease  has 
lasted  for  a  few  days,  even  if  no  fluctuation  can  be  made  out. 

Hydronephrosis. 

Definition. — Dilatation  of  the  pelvis  and  calyces  of  the  kidney. 

Etiology. — Dilatation  of  the  pelvis  and  calyces  of  one  or  of 
both  kidneys  can  be  produced  by  any  mechanical  obstruction  to 
the  escape  of  urine. 

Such  an  obstruction  may  begin  during  foetal  life,  so  that  when 
the  child  is  born  both  ureters  and  the  pelves  of  both  kidneys  are 
found  niuch  dilated.  Such  children  die  soon  after  birth.  The 
hydronephrosis  in  these  cases  is  due  to  some  congenital  malfor- 
mation, but  occasionally  we  see  this  condition  in  children  in 
whom  it  is  very  difficult  to  find  the  seat  of  obstruction.  It  is 
supposed  that  in  these  cases  there  exists  a  membranous  obstruc- 
tion which  is  broken  by  the  probe  used  to  explore  the  urethra. 

In  adults  the  mechanical  cause  of  the  obstruction  to  the 
escape  of  urine  may  be  situated  in  the  ureter,  bladder,  or  ure- 
thra, or  in  the  abdominal  cavity  near  the  ureters.  According  to 
the  position  of  the  obstruction,  either  one  or  both  kidneys  are 
aft'ected. 

Morbid  Anatomy. — The  pelves  and  calyces  of  the  affected  kid- 
ney are  more  or  less  dilated  ;  the  mucous  membrane  is  thin  and 
shining,  or  thickened.  The  kidney  tissue  becomes  more  and 
more  thinned  as  the  dilatation  goes  on,  and  after  a  time  in  the 
thinned  kidney  a  chronic  nephritis  is  set  up.  Then  there  is  a 
growth  of  new  connective  tissue  in  the  stroma  of  the  pyramids 
and  cortex  ;  in  some  of  the  glomeruli  there  is  a  growth  of  the 
cells  covering  the  capillaries,  while  other  glomeruli  are  atro- 
phied ;  degeneration  of  the  renal  epithelium  and  thickening  of 
the  walls  of  the  arteries  are  also  present. 

Symptoms. — The  patients  suffer  for  a  considerable  length  of 
time  from  the  inconveniences  belonging  to  the  retention  of 
urine.  If  the  retention  be  due  to  stricture  of  the  urethra  or  to 
disease  of  the  bladder,  the  entire  history  is  straightforward.     Ob- 


354  PYELITIS. 

struction  of  the  ureters,  however,  may  give  no  evidence  of  their 
existence,  and  we  find  after  death  strictures  of  one  or  both 
ureters,  for  which  we  are  unable  to  account. 

It  is  not  uncommon  to  find  after  death  well-marked  hydro- 
nephrosis of  one  or  both  kidneys  in  patients  who  have  had  no 
renal  symptoms  at  all. 

In  some  cases,  after  a  time,  there  is  developed  in  the  com- 
pressed kidneys  a  chronic  productive  nephritis  with  a  little  exu- 
dation. Then  the  specific  gravity  of  the  urine  gradually  falls,  a 
small  quantity  of  albumin  and  a  few  casts  make  their  appear- 
ance. The  quantity  of  the  urine  remains  normal,  or  is  increased, 
or  diminished,  or  suppressed.  The  patients  may  at  any  time 
have  contraction  of  the  arteries  with  an  elevated  temperature 
and  cerebral  symptoms,  or  they  may  pass  into  the  condition  of 
chronic  uraemia  with  a  feeble  pulse  and  low  temperature. 

In  other  cases  the  most  prominent  symptom  is  the  presence 
of  a  tumor  in  the  abdominal  cavity.  The  disease  is  then  usually 
confined  to  one  kidney.  The  tumor  lies  in  the  region  of  the 
loin,  extending  upward,  downward,  and  forward  as  it  increases  in 
size,  and  pushing  the  intestines  forward  and  to  one  side.  The 
surface  of  these  tumors  may  become  inflamed  and  adhesions 
formed  to  the  surrounding  tissues.  As  they  become  larger  they 
give  rise  to  much  discomfort  and  pain.  The  tumors  feel  like 
cysts.  From  time  to  time  they  may  diminish  in  size,  with  an  in- 
creased flow  of  urine  from  the  bladder  ;  they  are  not  movable. 
If  the  disease  is  caused  by  renal  calculi,  there  may  be  attacks  of 
renal  colic  with  bloody  urine.  If  the  fluid  from  the  tumor 
is  drawn  off  it  usually  contains  urinary  salts,  but  sometimes  it  is 
only  clear  serum. 

In  still  other  cases  of  hydronephrosis  a  suppurative  inflamma- 
tion attacks  the  pelvis  of  the  kidney,  and  the  patient  suffers  from 
pyelitis. 

Treatment. — The  treatment  of  hydronephrosis  is  altogether 
surgical.  If  possible  the  cause  of  the  retention  of  urine  must  be 
removed.  If  large  cvsts  are  formed,  they  must  be  opened  or  re- 
moved. 

Pyelitis. 

It  has  already  been  mentioned,  in  describing  suppurative 
nephritis,  that  with  acute  or  chronic  cystitis  there  may  be  an  ex- 
tension of  the  inflammation  from  the  bladder  to  the  pelves  of  the 


PYELITIS.  355 

kidneys,  with  suppurative  inflammation  of  the  pelves  and  of  the 
kidneys  themselves.  In  this  form  of  acute  pyelitis  the  inflam- 
mation of  the  kidney  is  more  important  than  that  of  the  pelves. 

Calculi  in  the  pelvis  of  the  kidney  often  set  up  a  pyelitis, 
which  will  be  described  with  the  account  of  renal  calculi. 

An  acute  catarrhal  pyelitis  is  said  to  be  caused  by  the  use  of 
turpentine  and  of  cantharides,  also  by  typhoid  fever  and  the  ex- 
anthemata. It  lasts  but  a  short  time  and  gives  rise  to  no  symp- 
toms of  importance. 

The  important  form  of  pyelitis  is  the  chronic  inflammation 
which  most  frequently  follows  cystitis,  sometimes  succeeds  hy- 
dronephrosis, and  rarely  seems  to  be  a  primary  inflammation. 
While  in  most  cases  the  pyelitis  is  clearly  secondary  to  the  cys- 
titis, it  may  very  well  happen  that  the  bladder  will  get  well, 
while  the  pyelitis  continues.  In  the  pyelitis  which  follows  preg- 
nancy it  is  not  always  easy  to  say  whether  the  inflammation  is 
due  to  the  temporary  hydronephrosis  or  to  the  cystitis  caused  by 
infected  catheters. 

Morbid  Anatomy. — The  mucous  membrane  of  the  pelvis  and 
calyces  is  thickened,  its  stroma  more  or  less  infiltrated  with  cells, 
the  layer  of  epithelium  thickened  in  some  places,  thinned  in 
others,  its  surface  coated  with  mucus  or  muco-pus.  The  pelvis 
and  calyces  are  more  or  less  dilated  :  they  may  contain  uric  acid 
or  oxalate  of  lime  calculi,  which  have  caused  the  inflammation  ; 
or  phosphatic  concretions  which  are  the  result  of  it.  In  the 
kidney  itself  there  may  be  a  growth  of  connective  tissue  in  the 
stroma  of  the  pyramids  and  cortex,  with  degeneration  of  the 
epithelium  and  atrophy  of  the  glomeruli,  or  a  suppurative  in- 
flammation which  may  destroy  considerable  portions  of  the 
kidney. 

Symptoftis. — In  the  majority  of  the  patients  the  symptoms  of 
the  cystitis,  of  the  enlarged  prostate,  or  of  the  stricture  of  the 
urethra  are  prominent  features  of  the  case. 

So  far  as  the  pyelitis  is  concerned,  the  patients  have  pain  and 
tenderness  referred  to  the  position  of  the  diseased  kidney.  The 
urine  from  time  to  time  contains  blood,  mucus,  and  epithelial 
cells  from  the  pelvis  of  the  kidney  ;  later  in  the  disease  many 
pus-cells  are  mixed  with  the  urine,  and  sometimes  phosphatic 
concretions.  The  urine  is  more  frequently  acid  than  is  the  case 
with  cystitis.  The  pus  may  be  discharged  continuously,  or  the 
ureter  may  from  time  to  time  become  occluded,  and  the  urine 


356  HEMORRHAGIC   PYELITIS. 

■* 

coming  from  the  other  kidney  will  be  clear  until  the  obstruction 
is  overcome  ;  then  a  large  quantity  of  purulent  urine  will  again 
be  discharged. 

In  some  patients  the  purulent  inflammation  of  the  pelvis  con- 
tinues ;  more  or  less  suppurative  inflammation  of  the  kidney  is 
added  ;  there  are  also  progressive  loss  of  flesh  and  strength, 
chills,  hectic  fever,  waxy  degeneration  of  the  viscera,  and  the 
patients  finally  die  exhausted  by  the  disease. 

The  distention  of  the  pelvis  of  the  kidney  may  be  so  great  as 
to  form  a  fluctuating,  painful  tumor  of  considerable  size.  If  the 
ureter  is  not  entirely  occluded,  the  pus  will  escape  from  time  to 
time  with  a  corresponding  change  in  the  size  of  the  tumor. 

Occasionally,  after  a  time  the  purulent  discharge  ceases,  the 
pelvis  contracts,  the  kidney  is  atrophied,  and  the  patient  gets 
well  with  one  useful  kidney.  In  some  of  the  cases  the  secondary 
nephritis  after  a  time  gives  symptoms.  The  specific  gravity  of 
the  urine  falls,  the  patients  lose  flesh  and  strength,  become 
anaemic,  have  more  or  less  dropsy,  and  finally  have  acute  cere- 
bral symptoms  or  pass  into  the  condition  of  chronic  uraemia. 

If  phosphatic  concretions  are  formed  in  the  pelvis,  fragments 
are  liable  to  come  away  from  time  to  time  and  cause  attacks  of 
renal  colic.  Or  it  is  possible  for  such  fragments  to  become  im- 
pacted in  the  ureters  and  cause  fatal  suppression  of  urine. 

Hemorrhagic  Pyelitis. 

Cases  characterized  by  intermittent  attacks  of  pain  over  one 
kidney  and  bloody  urine,  or  of  bloody  urine  alone,  are  of  not  un- 
common occurrence.  Only  a  moderate  number  of  these  cases 
have  found  their  way  into  print,  but  conversation  with  physi- 
cians and  surgeons  shows  the  existence  of  many  unreported 
cases.  The  symptoms  may  follow  either  a  mild  or  a  severe 
course. 

The  milder  form  of  the  disease  seems  to  be  of  most  common 
occurrence  in  young  girls.  The  only  marked  symptom  is  the  ap- 
pearance in  the  urine,  for  days  or  weeks,  of  red  and  white  blood- 
cells  and  of  epithelium  from  the  pelvis  of  the  kidney.  The  patients 
may  also  suffer  from  hysteria  and  from  disturbances  of  digestion. 
After  one  or  more  of  such  attacks  the  patients  recover  alto- 
gether. No  treatment  is  necessary  except  to  relieve  disturbances 
of  digestion  and  improve  the  general  health. 


RENAL   CALCULI.  357 

The  severe  form  of  the  disease  is  seen  both  in  males  and 
females.  From  time  to  time  the  patients  suffer  from  attacks  of 
pain  referred  to  one  kidney,  and  at  the  same  time  the  urine  con- 
tains large  quantities  of  blood.  With  the  cystoscope  the  blood 
can  be  seen  to  come  from  the  ureter  belonging  to  the  affected 
kidney.  Some  patients  after  a  number  of  such  attacks  have  no 
further  trouble  and  recover  entirely.  In  others,  however,  the 
pain  is  so  intense,  or  the  loss  of  blood  so  threatening,  that  surgi- 
cal operations  have  been  undertaken  for  their  relief,  usually  with 
the  expectation  of  finding  calculi  in  the  kidney.  These  kidneys 
have  been  simply  cut  down  on  and  felt  of,  or  needled,  or  split 
open,  or  extirpated.  It  is  a  curious  fact  that  recoveries  are  re- 
ported after  each  one  of  these  operative  procedures. 

In  the  onlv  one  of  these  kidneys  which  I  have  had  the  oppor- 
tunity of  examining  after  extirpation,  the  kidney  tissue  itself 
was  normal  and  contained  no  blood  in  the  tubes  or  stroma.  The 
mucous  membrane  of  the  pelvis  and  calyces  was  much  thickened, 
its  stroma  infiltrated  with  cells,  and  the  epithelium  irregular. 

Treaitnent. — The  stricture  of  the  urethra,  enlarged  prostate, 
cystitis,  or  other  cause  of  the  pyelitis  is  to  be  removed  as  entirely 
as  possible.  For  the  chronic  pyelitis  the  improvement  of  the 
general  health,  an  out-of-door  life  in  a  suitable  climate,  and 
the  use  of  such  waters  as  those  of  Ems  and  Poland  Springs  are 
often  of  great  service.  A  considerable  number  of  drugs  have 
been  employed  for  the  cure  of  pyelitis — the  mineral  acids,  the 
tincture  of  the  chloride  of  iron,  the  alkalies,  the  vegetable  astrin- 
gents, saloT,  belladonna,  and  others.  In  pyelitis  in  the  female 
good  results  are  reported  from  washing  out  the  pelvis  through 
the  ureter.  If  the  distention  of  the  pelvis  with  purulent  fluid  is 
very  great,  or  if  the  kidney  itself  undergo  suppuration,  the  kid- 
ney must  either  be  opened  or  removed.  The  systoscope  is  of 
much  service  in  locating  the  kidney  in  which  the  pyelitis  is 
situated. 

Renal  Calculi. 

The  solid  constituents  of  the  urine  may  be  precipitated  in  the 
pelves  of  the  kidneys  in  the  form  of  sand,  gravel,  or  calculi. 
The  calculi  are  formed  of  uric  acid,  of  uric  acid  with  a  shell  of 
oxalate  of  lime,  of  oxalate  of  lime,  or  of  the  phosphates.  Calculi 
composed  of  cystin  are  of  a  light -yellow  color  and  lustrous, 
looking  something  like   beeswax  ;  they   are  of  rare   occurrence. 


358  RENAL   CALCULI. 

Calculi  composed  of  xanthin,  of  fatty  or  saponaceous  matters,  of 
carbonate  of  lime  and  of  fibrin  have  been  described  in  rare 
cases. 

Etiology. — Renal  calculi  are  found  in  persons  of  all  ages  ;  they 
are  of  more  frequent  occurrence  in  males  than  in  females.  A 
sedentary  life,  gout,  any  conditions  which  produce  an  exag- 
gerated excretion  of  uric  acid,  of  oxalate  of  lime,  of  phosphates, 
or  of  cystin,  or  inflammation  of  the  pelves  of  the  kidneys,  may 
act  as  causes. 

Syjnptoms. — Small  calculi  may  be  formed  in  the  pelves  of  the 
kidneys,  be  passed  through  the  ureters  into  the  bladder,  and 
finally  escape  through  the  urethra  without  giving  any  trouble. 

Larger  calculi,  which  are  formed  in  the  pelves  and  pass 
through  the  ureters,  cause  by  their  passage  attacks  of  renal  colic. 
During  an  attack  of  renal  colic  the  patients  have  severe  pain, 
coming  on  suddenly  or  gradually,  referred  to  the  position  of  the 
kidney  and  ureter  and  radiating  down  into  the  groin,  or  simply  a 
diffuse  abdominal  pain.  The  testicle  is  retracted,  sometimes 
painful  and  swollen.  Occasionally  the  pain  is  so  severe  that  the 
patients  faint  or  have  general  convulsions.  Vomiting  or  retch- 
ing is  sometimes  frequently  repeated  and  very  distressing. 
There  may  be  a  moderate  rise  of  temperature. 

The  urine,  during  the  attack,  is  passed  frequently,  in  small 
quantities,  often  with  a  good  deal  of  pain,  and  may  contain  blood. 
After  the  attack  a  considerable  quantity  of  urine  is  passed,  which 
for  a  time  may  be  bloody. 

Most  attacks  of  renal  colic  last  only  for  a  few  hours,  but  they 
may  be  prolonged,  with  intermissions,  for  a  number  of  days.  The 
same  patient  may  have  one  attack  or  several  attacks. 

The  calculus,  instead  of  getting  through  the  ureter  into  the 
bladder,  may  become  impacted.  If  the  patient  has  only  one  kid- 
ney, or  if  the  kidneys  of  both  ureters  are  obstructed,  the  urine  is 
entirely  suppressed,  and  the  patients  die  after  a  number  of  days 
in  the  condition  of  chronic  uraemia.  If  the  ureter  of  only  one 
kidney  is  obstructed,  either  hydronephrosis  or  pyonephrosis  is 
apt  to  follow. 

The  calculi,  after  being  formed  in  the  pelvis  of  the  kidney, 
may  remain  there.  When  this  happens  the  patient  may  never 
have  any  symptoms,  nor  any  considerable  change  in  the  kidney  ; 
but  without  any  symptoms  the  kidney  may  become  atrophied. 
More  frequently  the  patients  have  repeated  attacks  of  pain  over 


RENAL   CALCULI.  359 

one  kidney  and  bloody  urine.  After  a  number  of  attacks  they 
may  finally  pass  a  calculus.  If  the  attacks  cease  and  no  calculus 
is  passed,  we  cannot  be  certain  whether  the  patient  has  a  renal 
calculus  or  has  had  a  hemorrhagic  pyelitis. 

Very  often  the  calculus  acts  as  an  irritant  and  sets  up  inflam- 
matory changes  in  the  pelvis  or  in  the  kidney.  Or  instead  of 
this,  a  pyelitis  is  followed  by  the  formation  of  phosphatic  calculi. 

If  there  is  a  chronic  pyelo-nephritis,  the  patients  have  pain 
and  tenderness  over  the  diseased  kidney,  either  continuously  or 
in  attacks.  The  urine  at  intervals  contains  pus  and  blood,  some- 
times fragments  of  the  calculi.  The  dilatation  of  the  pelvis  of 
the  kidney  may  form  a  tumor  of  appreciable  size.  The  patients 
lose  flesh  and  strength,  they  have  an  irregular  fever,  they  are 
liable  to  have  chronic  nephritis  of  the  other  kidney,  or  waxy  de- 
generation of  the  viscera. 

In  some  cases  the  calculus  causes  but  little  change  in  the  pel- 
vis of  the  kidney,  but  the  kidney  itself  becomes  the  seat  of 
chronic  diffuse  nephritis  with  a  little  exudation.  The  urine  then 
becomes  of  low  specific  gravity  and  contains  a  little  albumin. 
The  patients  are  liable  to  attacks  of  contraction  of  the  arteries, 
with  dyspnoea  or  cerebral  symptoms,  or  they  may  become  some- 
what dropsical. 

Treatment. — To  prevent  the  formation  of  uric  acid  and  oxalate 
of  lime  calculi  we  regulate  the  diet  by  excluding  starch  and 
sugar.  We  insist  on  sufficient  exercise  in  the  open  air.  The 
patients  should  spend  several  weeks  every  year  at  one  of  the  al- 
kaline springs,  or  should  take  from  time  to  time  one  of  the  alka- 
lies largely  diluted  with  water.  Piperazin  is  recommended  in 
doses  of  from  5  to  10  grains  dissolved  in  large  quantities  of  water. 
Urotropin  is  also  given  in  doses  of  20  grains  daily,  dissolved  in 
water  and  taken  at  one  dose  in  the  morning. 

The  treatment  of  the  attacks  of  renal  colic  is  directed  to  the 
relief  of  the  pain  and  to  hastening  the  passage  of  the  calculus. 
The  means  usually  employed  for  this  purpose  are  hypodermic  in- 
jections of  morphine,  inhalations  of  ether  and  chloroform,  and  the 
hot  baths.  The  use  of  doses  of  30  drops  of  tr.  belladonnae  every 
two  to  three  hours,  until  slight  delirium  is  produced,  has  been 
employed  to  cut  short  the  attacks  and  favor  the  passage  of  the 
calculus. 

A  calculus  in  the  pelvis  of  the  kidney,  or  one  impacted  in  the 
ureter,  can  only  be  removed  by  a  surgical  operation. 


GLYCOSURIA. 


Sugar  may  be  present  in  the  urine  as  a  temporary  condition, 
or  persist  in  moderate  quantity  for  some  time,  although  the 
patients  do  not  have  diabetes. 

Certain  poisons  may  cause  temporary  glycosuria :  curare, 
carbonic-acid  gas,  nitrite  of  amyl,  morphine,  chloral  hydrate, 
cyanide  of  potash,  sulphuric  acid,  mercury,  alcohol,  and  chloro- 
form. 

With  some  of  the  infectious  diseases  sugar  may  be  found  in 
the  urine  :  cholera  in  the  stage  of  reaction,  anthrax,  diphtheria, 
typhoid  fever,  scarlatina,  remittent  fever,  and  cerebro-spinal 
meningitis. 

Gastric  catarrh,  functional  disorders  of  the  liver,  gout,  and 
imperfect  digestion  of  sugars  and  starches  may  be  accompanied 
by  the  presence  of  sugar  in  the  urine. 

Sugar  may  also  be  found  in  the  urine  after  mental  emotions, 
trigeminal  neuralgia,  concussion  of  the  brain,  cerebral  apoplexy, 
with  atrophied  kidneys,  and  during  pregnancy. 

Such  a  temporary  presence  of  sugar  is  usually  not  of  impor- 
tance, but  it  may  be  followed  by  diabetes. 


DIABETES  MELLITUS. 


Causes. — This  is  a  disease  characterized  by  an  increased  pro- 
duction of  urine,  by  the  presence  of  sugar  in  the  urine,  and  by 
changes  in  the  general  health  of  the  patient. 

In  adults  the  disease  is  twice  as  common  in  men  as  in  wom- 
en. It  is  especially  frequent  in  young  and  middle-aged  adults, 
but  it  is  not  rare  in  children  and  old  persons.  It  is  more  preva- 
lent among  the  well-to-do  than  among  the  poor.  It  is  found  in 
nearly  all  parts  of  the  world,  but  is  more  prevalent  in  some  lo- 
calities than  in  others.  There  seems  to  be  an  inherited  predis- 
position to  the  disease. 

Lesions. — The  brain  is  seldom  entirely  normal  in  persons  who 
die  from  diabetes,  but  the  changes  found  in  it  seem  to  be  the  re- 
sult rather  than  the  cause  of  the  disease.  The  brain  itself  may 
be  oederaatous  and  congested  ;  or  softened  ;  or  studded  with 
minute  hemorrhages  ;  or  with  enlargement  of  the  peri-vascular 
spaces  ;  or  with  small  cysts  in  the  white  matter.  The  pia  may  be 
thickened. 

In  rare  cases  tumors  of  the  medulla,  the  pons,  or  the  cere- 
bellum have  been  found,  which  have  been  looked  on  as  the  cause 
of  the  diabetes. ' 

The  heart  muscle  may  be  the  seat  of  fatty  degeneration  or  of 
glycogenic  degeneration. 

In  the  blood  haemoglobin  and  the  red  blood-cells  are  de- 
creased, the  sugar  is  increased  in  quantity. 

The  lungs  may  be  simply  congested  and  oedematous  ;  more 
frequently  they  are  the  seat  of  a  tubercular  pneumonia  ;  occa- 
sionally portions  of  them  become  gangrenous. 

The  liver  maybe  infiltrated  with  fat,  or  cirrhotic.  In  a  few- 
cases  abscesses  have  been  found  in  it. 

The  pancreas  is  the  only  part  of  the  body  of  which  the  diseases 
really  seem  to  cause  diabetes.     Extirpation   of  the  pancreas  in 


362  DIABETES   MELLITUS. 

animals  and  in  man  seems  to  be  regularly  followed  by  a  true  dia- 
betes. In  persons  who  die  from  diabetes  the  pancreas  is  often 
found  to  be  much  changed  by  interstitial  inflammation,  with  a 
growth  of  new  connective  tissue  and  degeneration  of  the  epithel- 
ial cells. 

The  kidneys  are  usually  more  or  less  changed.  They  may 
be  the  seat  of  chronic  degeneration,  or  of  chronic  nephritis 
with  exudation.  The  epithelial  cells  of  Henle's  loops  are 
often  changed  by  hyaline  degeneration,  or  contain  masses  of 
glycogen. 

The  nature  of  the  disease  is  still  involved  in  obscurity.  Sugar 
is  introduced  into  the  body  as  part  of  the  food,  and  is  also  formed 
in  the  tissues.  Normally,  this  sugar  is  afterward  changed  into 
other  substances.  In  diabetes,  either  there  is  a  failure  in  this 
destruction  of  sugar,  or  too  much  sugar  is  produced  in  the 
tissues,  or  both  these  conditions  are  present  at  the  same  time. 

Symptoms. — It  has  long  been  observed  that  there  are  mild  and 
severe  cases  of  diabetes,  and  that  the  differences  between  these 
two  sets  of  cases  are  so  strii^ing  that  it  is  difficult  to  believe  the 
patients  are  suffering  from  the  same  disease.  On  the  other 
hand,  mild  cases  may  gradually  change  into  severe  ones,  and 
there  also  exists  an  intermediate  set  of  cases,  neither  very  mild 
nor  very  severe. 

In  the  mild  cases  the  urine  is  considerably  increased  in  quan- 
tity and  contains  a  moderate  quantity  of  sugar.  The  general 
health  of  the  patients  is  but  little  affected.  They  complain  of 
thirst,  of  disturbances  of  digestion,  of  a  little  loss  of  flesh  and 
strength.  If  the  sugars  and  starches  are  excluded  from  their 
food,  the  quantity  of  urine  diminishes  and  the  sugar  disappears. 
If  a  strict  diet  is  kept  up  for  some  time  the  patients  may  later 
be  able  to  return  to  the  use  of  sugar  and  starch,  and  still  remain 
well. 

In  the  intermediate  cases  the  quantity  of  urine  and  of  sugar 
is  larger,  and  the  loss  of  nutrition  is  much  more  marked.  It  re- 
quires the  strictest  diet,  and  sometimes  in  addition  medical  treat- 
ment, to  entirely  get  rid  of  the  sugar  in  the  urine.  It  is  much 
more  difficult  to  get  the  patients  into  such  a  condition  that  they 
can  return  to  an  ordinary  diet  without  a  recurrence  of  the  sugar 
in  the  urine. 

In  the  severe  cases  the  quantity  of  urine  and  of  sugar  is  very 
large.     The  patients  have  a  troublesome  thirst  and  an  unnatural 


DIABETES   MELLITUS.  363 

hunger.  Tlie  gums  become  unhealthy  and  bleed  easily,  and  the 
teeth  decay.  The  mouth  is  always  dry,  and  often  coated  with  a 
tenacious  mucus.  The  functions  of  the  stomach,  liver,  and  in- 
testines are  disturbed  in  various  ways.  The  patients  lose  muscu- 
lar strength,  and  gradually  become  more  and  more  emaciated. 
Neither  the  strictest  diet  nor  medical  treatment  will  cause  the 
sugar  to  disappear  from  the  urine.  After  a  time  one  of  the  com- 
plicating lesions  will  be  developed — the  furuncles,  the  tubercular 
pneumonia,  the  degeneration  of  the  kidney,  the  chronic  ne- 
phritis, the  gangrene  of  the  feet. 

As  a  rule,  these  severe  cases  of  diabetes  begin  slowly  and  grad- 
ually, and  life  is  not  destroyed  until  after  a  number  of  years.  But 
occasionally  we  see  cases  in  which  the  disease  seems  to  run  its 
course  within  a  few  months  or  weeks. 

The  patients  who  have  the  severe  form  of  diabetes  are  liable 
at  any  time  to  have  an  attack  of  diabetic  coma.  The  group  of 
symptoms  called  by  this  name  may  follow  one  of  three  types  : 

1.  After  some  unusual  bodily  or  mental  exertion  the  patients 
suddenly  feel  very  weak.  The  skin  is  cold,  the  pulse  is  feeble, 
they  become  stupid,  then  comatose,  and  die  in  a  few  hours. 

2.  For  from  six  to  nine  days  the  patients  complain  of  weak- 
ness, constipation,  loss  of  appetite,  slight  drowsiness,  breathless- 
ness,  and  pain  in  the  abdomen.  Then  come  on  headache,  rest- 
lessness, delirium,  abdominal  pain,  rapid  and  labored  breathing, 
cyanosis,  a  feeble  and  rapid  heart,  stupor,  and  coma.  The  pa- 
tients die  within  a  few  days. 

3.  There  is  no  dyspnoea  or  prostration,  but  sudden  headache, 
vertigo,  stupor,  coma,  and  death  within  a  few  hours. 

We  are  still  ignorant  of  the  exact  nature  of  these  very  fatal 
attacks.  It  has  been  supposed  that  they  are  caused  by  changes 
in  the  nerve-centres,  by  the  inspissation  of  the  blood,  by  fat  em- 
bolism, by  uraemia,  or  by  acetonaemia. 

In  the  mild  cases  the  prognosis  is  very  good,  in  the  interme- 
diate cases  it  is  doubtful,  in  the  severe  cases  it  is  bad.  Children 
do  much  worse  than  adults.  Old  people  often  bear  the  disease 
very  well. 

Treatment. — We  usually  try,  first,  the  regulation  of  the  diet 
and  of  the  mode  of  life.  If  these  are  not  successful,  we  must 
add  the  use  of  drugs. 

The  regulation  of  the  diet  consists  in  cutting  ofif  from  the 
food  the  sugars  and  starches. 


364  DIABETES   MELLITUS. 

The  patients  may  eat  :  Meat,  fish,  soups,  almond,  bran,  or 
gluten  bread,  eggs,  cream,  butter,  cheese,  oil,  spinach,  turnips, 
beans,  cauliflower,  cabbage,  asparagus,  lettuce,  celery. 

They  must  not  eat  :  Sugar,  wheaten  bread,  rice,  sago,  arrow- 
root, tapioca,  macaroni,  potatoes,  carrots,  parsnips,  beets,  peas, 
onions,   and  fruits. 

They  should  not  drink  wines  or  liquors. 

It  is  necessary,  however,  to  take  the  greatest  care  not  to  ex- 
clude the  starches  and  fruits  so  rigidly  that  the  patients  are  in- 
sufficiently fed. 

The  regulation  of  the  mode  of  life  consists  in  seeing  that  the 
patients  lead  an  out-door  life,  with  sufficient  exercise. 

The  drugs  which  are  ordinarily  used  are  :  The  preparations 
of  opium.  The  bicarbonate  and  salicylate  of  soda,  about  one 
hundred  grains  daily.  The  alkaline  waters  of  Carlsbad  and 
Vichy.  The  sulphide  of  calcium,  one-quarter  of  a  grain  to  two 
grains  four  times  a  day.  Clemen's  solution  of  bromide  of  arsenic, 
five  to  twenty  minims  three  times  a  day.  The  carbonate  of 
lithia  and  arseniate  of  soda  dissolved  in  large  quantities  of  water. 
Iodoform,  one-half  a  grain  to  two  grains  three  times  a  day.  Jam- 
bol  in  powder,  ten  grains  three  times  a  day.  Antipyrin,  ten  to 
twenty  grains  three  times  a  day.  Pilocarpine,  one-twelfth  of  a 
grain  twice  a  day. 


DIABETES  INSIPIDUS. 


This  is  a  disease  characterized  by  the  passage  of  large  quan- 
tities of  urine  of  low  specific  gravity,  the  condition  not  being 
due  to  disease  of  the  kidneys. 

Causes. — The  disease  usually  occurs  in  young  adults.  It  is 
more  common  in  males  than  in  females.  We  know  nothing  con- 
cerning its  nature  and  causes. 

Symptoms. — The  patients  pass  large  quantities  of  urine  of  low 
specific  gravity.  They  complain  of  continual  thirst,  of  loss  of 
flesh,  of  disturbances  of  digestion,  and  of  a  variety  of  hysterical 
and  nervous  symptoms. 

In  some  of  the  patients  the  disease  is  readily  relieved  by 
treatment  ;  in  others  it  is  persistent  and  annoying  ;  but  even  in 
the  worst  cases  it  is  not  fatal. 

Treatment. — The  drugs  ordinarily  used  are  ergot,  gallic  acid, 
the  pi-eparations  of  valerian,  the  mineral  acids,  and  combinations 
of  sodium  bromide  with  nux  vomica.  Some  patients  are  bene- 
fited by  the  exclusive  diet  of  meat  and  hot  water. 


HEMOGLOBINURIA. 


I.  Idiopathic  Cases. 

Causes. — This  condition  has  been  observed  in  persons  of  all 
ages,  but  more  frequently  in  females  than  in  males.  Similar 
conditions  can  be  produced  experimentally  in  animals  by  inject- 
ing into  their  veins  distilled  water,  glycerine,  or  pyrogallic  acid. 
In  man  the  attacks  are  often  produced  by  a  sudden  cooling  of 
the  skin. 

There  is  apparently,  at  the  time  of  an  attack,  first  a  sudden 
destruction  of  red  blood-cells  and  liberation  of  their  haemoglobin 
in  the  general  circulation  ;  second,  an  excretion  by  the  kidneys 
of  the  haemoglobin  which  has  thus  been  liberated. 

The  symptoms  manifest  themselves  in  paroxysms.  Between 
the  paroxysms  the  urine  is  normal,  and  the  patients  seem  to  be 
well. 

The  paroxysms  commence  with  chilliness,  or  a  chill  lasting 
from  half  an  hour  to  two  hours.  At  the  same  time  nausea,  vom- 
iting, and  more  or  less  prostration  are  present.  After  the  chill 
there  may,  or  may  not,  be  a  rise  of  temperature.  The  first  urine 
passed  after  the  chill  is  of  red  or  brown  color,  as  if  mixed  with 
blood.  It  contains,  however,  no  blood-cells,  only  haemoglobin. 
The  specific  gravity  of  the  urine  remains  unchanged  ;  albumin 
and  casts  are  present.  The  haemoglobin  is  found  in  the  urine  for 
one  or  more  days  after  the  chill. 

The  attacks  may  be  repeated  several  times  a  day,  or  at  longer 
intervals.  They  may  be  repeated  a  number  of  times  during  a 
month,  stop  for  several  months,  and  then  begin  again. 

The  patients  may  also  be  troubled  by  disturbances  of  diges- 
tion and  some  loss  of  flesh  and  strength. 

All  of  the  patients  seem,  after  a  time,  to  recover. 

Treatjuent  is  directed  to  improvement  of  the  general  health 
and  avoidance  of  cooling  the  skin. 


H/EMOGLOBINURIA.  367 

2.  Malarial  Cases. 

A  patient  may  have  a  number  of  ordinary  paroxysms  of  inter- 
mittent fever,  and  then  one  or  more  paroxysms  followed  by  the 
appearance  of  haemoglobin  in  the  urine. 

The  malignant  forms  of  remittent  fever  are  sometimes  accom- 
panied by  the  presence  of  haemoglobin  in  the  urine. 


PERITONITIS. 


Acute  Peritonitis. 

Lesions. — There  are  two  anatomical  forms  of  acute  peritonitis  : 
a  productive  inflammation  with  the  growth  of  cells,  and  an  exu- 
dative inflammation  with  the  production  of  serum,  fibrin,  and 
pus. 

1.  Cellular  Peritonitis. — The  peritoneum  is  congested  and 
without  its  natural  glistening  appearance.  There  is  an  increase 
in  the  size  and  number  of  the  endothelial  cells,  but  neither  fibrin, 
serum,  or  pus  is  present.  The  intestines  are  distended  with 
gas. 

2.  Exudative  Peritonitis. — The  peritoneum  is  at  first  con- 
gested. Its  surface  is  coated  with  fibrin,  or  with  fibrin  and  pus, 
which  makes  adhesions  between  the  opposed  surfaces  of  perito- 
neum. In  the  peritoneal  cavity,  or  shut  in  by  adhesions,  are  collec- 
tions of  purulent  or  brownish  serum.  The  subperitoneal  tissue 
may  be  infiltrated  with  pus-cells.  The  intestines  are  distended 
with  gas.  In  the  more  prolonged  cases  there  is  a  growth  of  new 
connective  tissue-cells  and  a  formation  of  permanent  thicken- 
ings and  adhesions  after  the  absorption  of  the  serum,  fibrin,  and 
pus. 

Causes. — Cellular  peritonitis  seems  to  be  caused  simply  by 
some  irritant.  Exudative  peritonitis  is  caused  by  an  irritant  and 
by  the  growth  of  pathogenic  bacteria. 

The  ordinary  causes  of  peritonitis  are  : 

Wounds  and  contu-sions  of  the  abdomen. 

Wounds,  ulcers,  new-growths,  incarcerations,  intussusceptions, 
ruptures,  perforations,  and  inflammations  of  the  stomach  and  in- 
testines. 

Inflammations  of  the  vermiform  appendix. 

Injuries  and  inflammations  of  the  uterus,  ovaries,  and  Fallo- 
pian tubes. 


PERITONITIS.  369 

Rupture  and  inflammation  of  the  bladder.  Inflammation  of 
the  kidneys. 

Abscesses  and  hydatid  cysts  of  the  liver.  Inflammation  of  the 
gall-bladder. 

Inflammation  of  the  spleen,  pancreas,  lymphatic  glands,  re- 
tro-peritoneal connective  tissue,  vertebrae,  ribs,  pelvic  bones,  and 
pleura. 

Thrombosis  of  the  portal  vein.  Peritonitis  may  complicate 
septicaemia,  the  infectious  diseases,  and  Bright's  disease.  Occa- 
sionally we  meet  with  cases  of  idiopathic  peritonitis. 

Symptotns. — The  symptoms  of  the  invasion  vary  with  the  char- 
acter of  the  cause  of  the  peritonitis.  With  an  idiopathic  perito- 
nitis the  invasion  is  sudden  or  more  gradual. 

More  or  less  chilliness  exists  during  the  first  day,  and  may  be 
repeated  later.  The  temperature  rises,  but  runs  a  very  irregular 
course.  In  some  patients  it  is  high  throughout  the  disease  ;  in 
others  it  rises  and  falls  irregularly  ;  in  still  others  it  will  hardly 
be  above  99°  F. 

The  intestines  become  distended  with  gas,  and  the  abdomen 
is  swollen  and  tense.  Such  a  tympanitic  condition  belongs  reg- 
ularly to  general  peritonitis,  but  it  is  also  found  with  the  local- 
ized forms  of  the  inflammation. 

In  most  cases  pain  and  tenderness  exist  over  those  portions 
of  the  abdomen  where  the  peritonitis  is  going  on.  The  pain  is 
increased  by  pressure,  by  motion,  and  by  the  act  of  breathing. 
The  patients  lie  on  their  backs,  with  their  knees  drawn  up,  and 
move  the  diaphragm  as  little  as  they  can.  It  is,  however,  not  a 
very  rare  exception  for  the  pain  to  be  absent  altogether. 

There  is  vomiting  of  food,  of  green  or  brown  fluid,  or  of  ster- 
coraceous  matter.  Often  there  is  no  active  vomiting,  but  every 
few  hours  there  is  a  regurgitation  of  brownish  fluid  and  of  what- 
ever food  the  patient  has  taken.  There  is  often  much  difficulty 
in  getting  the  patients  to  retain  any  nourishment  at  all. 

The  bowels  are  usually  constipated,  but  sometimes  there  is 
diarrhoea. 

The  pulse  is  rapid  and  feeble. 

The  breathing  is  rapid  and  shallow. 

The  patients  rapidly  lose  flesh  and  strength. 

The  tongue  becomes  dry  and  brown. 

The  mind  may  remain  clear,  or  alternating  stupor  and  delirium 
are  developed. 


370  PERITONITIS. 

After  childbirth  there  may  be  an  infection  of  and  through  the 
uterus,  which  gives  symptoms  like  those  of  peritonitis,  although 
a  real  peritonitis  is  not  always  present. 

1.  A  portion  of  the  membranes  or  a  blood-clot,  by  the  third 
or  fourth  day  after  childbirth,  may  become  putrid,  with  the 
growth  of  bacteria  and  the  formation  of  ptomaines.  The  patients 
at  once  have  chills,  fever,  marked  prostration,  pain  and  tender- 
ness, and  tympanites.  If  the  putrid  substance  is  expelled  from 
the  uterus,  all  these  symptoms  cease.  If  it  is  retained  in  the 
uterus  a  true  peritonitis  may  be  developed. 

2.  There  is  an  endometritis  with  pus  and  fibrin  coating  the 
inner  surface  of  the  uterus,  and  infiltrating  its  wall. 

3.  There  is  thrombosis  of  the  uterine  veins.  With  either  of 
these  conditions  there  may  be  a  pelvic,  or  a  general,  peritonitis. 
But  even  if  the  peritonitis  is  not  present  the  symptoms  are 
much  the  same. 

Treatment. — We  may  treat  an  acute  peritonitis  as  we  would 
any  other  acute  exudative  inflammation,  by  rest  in  bed,  the  local 
application  of  cold,  repeated  small  doses  of  calomel  or  the  sul- 
phate of  magnesia,  and  small  doses  of  opium. 

Or  we  may  adopt  the  opium  treatment,  which  consists  in  giv- 
ing such  doses  of  opium,  at  regular  intervals,  as  will  keep  the 
patient  in  a  condition  of  semi-narcotism  until  the  peritonitis  has 
run  its  course. 

Or  we  may  employ  surgical  treatment,  open  the  abdomen 
freely,  and  wash  out  the  pus  and  fibrin. 

Inflammation  of  the  Vermiform  Appendix. — The  vermiform 
appendix  is  given  off  from  the  inner  and  posterior  aspect  of  the 
lower  end  of  the  caput  coli.  It  is  from  three  to  six  inches  in 
length.  It  is  composed  of  a  peritoneal,  muscular,  and  glandular 
coat.  It  may  be  turned  upward  behind  the  caecum,  or  it  may 
hang  downward  free  in  the  peritoneal  cavity. 

Lesions. —  i.  There  may  be  a  catarrhal  inflammation  of  the 
mucous  membrane  of  the  appendix  ;  this  usuallv  gives  symptoms 
of  no  great  severity. 

2.  There  is  an  exudative  inflammation  of  the  entire  wall  of  the 
appendix.  The  wall  is  infiltrated  with  fibrin  and  pus,  but  there  is 
no  necrosis  of  the  wall  nor  perforation.  If  the  appendix  is  behind 
the  caecum,  or  if  adhesions  are  formed  early,  the  inflammation  is 
localized.  If  the  appendix  is  free  in  the  peritoneal  cavity  and  no 
adhesions  are  formed,  a  general  peritonitis  is  soon  established. 


PERITONITIS.  371 

3.  There  is  an  exudative  inflammation  of  the  appendix,  with 
necrosis,  sloughing,  and  perforation  at  one  or  more  parts  of  its 
wall.  This  is  regularly  attended  with  the  formation  of  an  abscess 
behind  the  caecum,  or  in  the  peritoneal  cavity. 

4.  The  entire  appendix  becomes  rapidly  gangrenous  with  the 
formation  of  an  abscess  or  a  general  peritonitis. 

5.  A  patient  may  recover  from  the  exudative  inflammation, 
or  from  the  inflammation  with  perforation,  and  then  have  subse- 
quent attacks  of  the  same  character. 

Causes.- — The  disease  is  most  common  in  persons  between  the 
ages  of  ten  and  thirty  years,  but  older  persons  are  not  exempt. 
In  many  cases  a  fecal  concretion,  or  a  foreign  body,  is  found  in 
the  appendix,  which  may  be  the  cause  of  the  inflammation. 

In  typhoid  fever,  and  in  dysentery,  there  may  be  an  inflamma- 
tion of  the  appendix  as  a  part  of  the  lesions  of  either  disease. 

Symptoms. — These  depend  upon  : 

The  inflammation  of  the  appendix. 

The  localized  peritonitis. 

The  formation  of  an  abscess. 

The  general  peritonitis. 

The  general  infection  produced  by  the  infectious  inflammation. 

The  cases  group  themselves  as  follows  : 

I.  Cases  which  terminate  in  resolution.  The  patients  may, 
for  hours  or  days  before  the  attack,  complain  of  colicky  pains, 
constipation,  diarrhoea,  or  a  diffuse  pain  over  the  entire  abdomen. 
Or,  without  any  such  premonitory  symptoms,  the  invasion  is  ab- 
rupt. 

There  are  chills,  or  chilliness,  a  rise  of  temperature,  vomiting, 
pain  and  tenderness  in  the  right  iliac  region,  within  forty-eight 
hours  a  decided  feeling  of  fulness  and  resistance  in  the  right  iliac 
region.  These  symptoms  continue  for  one  or  two  weeks  and 
then  subside,  and  the  patients  recover.  The  patients  may  have 
no  further  trouble  ;  they  may  have  pain  from'  time  to  time  from 
the  adhesions  ;  or  they  may  have  fresh  attacks  of  inflammation 
of  the  appendix. 

Such  a  course  of  the  disease  means  that  the  inflamed  appen- 
dix is  situated  behind  the  caecum,  and  that  no  abscess  is  formed. 

Treatment. — These  patients  do  so  well  that  operative  treatment 
seems  hardly  necessary.  Rest  in  bed,  a  fluid  diet,  emptying  of 
the  rectum  by  enemata,  and  the  application  of  continuous  cold 
over  the  right  iliac  region  are  the  essential  parts  of  the  treatment. 


372  PERITONITIS. 

2.  Cases  with  the  formation  of  an  abscess.  The  symptoms 
begin,  as  in  the  preceding  set  of  cases,  with  premonitory  symp- 
toms, or  abruptly.  But  although  the  symptoms  are  the  same, 
they  are  much  more  severe.  By  the  end  of  a  week  the  abscess 
is  formed.  There  is  now  a  more  distinct  tumor,  and  the  patients 
give  evidences  of  septic  poisoning.  The  position  of  the  abscess 
varies  with  that  of  the  appendix.  At  any  time  a  general  peri- 
tonitis may  be  set  up  by  extension  of  the  inflammation  or  by 
rupture  of  the  abscess. 

The  abscess  may  perforate  into  the  peritoneal  cavity,  the 
bladder,  or  the  colon.  There  may  be  suppurating  tracts  which 
extend  backward,  upward,  or  downward. 

The  patients  die  with  evidences  of  septic  infection  or  of  gen- 
eral peritonitis.  A  small  number  recover  with  escape  of  pus  into 
the  colon,  or  its  gradual  absorption. 

The  treatment  is  to  cut  down  on  the  inflamed  appendix  and 
remove  it  as  soon  as  the  diagnosis  can  be  made.  For  in  all  these 
cases  there  is  inflammation  and  perforation  of  the  appendix  and 
the  formation  of  an  abscess. 

3.  Cases  in  which  there  is  an  exudative  inflammation  of  the 
appendix  with  or  without  perforation  ;  the  appendix  is  not  be- 
hind the  caecum  ;  no  adhesions  are  formed  ;  a  general  peritonitis 
is  soon  developed. 

For  a  few  hours,  or  for  two  or  three  days,  the  patients  com- 
plain of  malaise,  nausea,  vomiting,  constipation  or  diarrhoea,  and 
abdominal  discomfort.  They  do  not  seem  to  be  very  ill,  and  are 
not  confined  to  bed.  Then  comes  suddenly  the  development 
of  an  acute  general  peritonitis,  with  marked  prostration,  fever, 
diffuse  pain  and  tenderness  over  the  abdomen,  vomiting,  tym- 
panites, a  brown,  dry  tongue,  and  an  anxious  face.  The  patients 
get  worse  rapidly  and  die  in  a  few  days. 

Treatment. — The  proper  treatment  is  to  operate  and  remove 
the  inflamed  appendix  as  soon  as  possible.  The  difficulty  is  to 
make  the  diagnosis  before  the  development  of  the  peritonitis. 
After  the  peritonitis  is  established,  the  operation  is  not  often 
successful. 

4.  Cases  in  which  the  entire  appendix  becomes  gangrenous 
within  a  few  hours.  The  patients  complain  first  of  general 
malaise,  chilliness,  nausea,  vomiting,  constipation  or  diarrhoea, 
pain  and  tenderness  in  the  right  iliac  region,  and  a  rise  of  tem- 
perature.    Within  twenty-four  hours  the  patients  look  as  if  they 


PERITONITIS.  373 

were  suffering  from  an  infectious  disease.  The  pain  and  tender- 
ness in  the  right  iliac  region  continue  ;  there  is  a  feeling  of  resist- 
ance in  this  region,  and  if  an  abscess  is  formed,  a  more  distinct 
tumor.  The  temperature  does  not  run  very  high,  but  the  pulse 
is  rapid  and  feeble,  and  the  patients  look  more  and  more  as  if 
they  were  poisoned.  The  abdomen  becomes  tympanitic,  the 
stomach  ceases  to  retain  food,  and  the  patients  die  at  the  end  of 
a  few  days. 

Treatment. — An  operation  at  the  earliest  possible  moment  is 
indicated  in  these  patients.  But  even  with  an  operation  they  are 
very  unfavorable  cases. 

It  is  to  be  noted  that  some  of  the  patients  do  not  refer  their 
pain  to  the  appendix,  but  to  some  other  part  of  the  abdomen  ; 
that  the  appendicitis  may  complicate  an  acute  colitis  ;  that  the 
secondary  abscesses  about  the  liver  and  the  right  lung  may  give 
more  marked  symptoms  than  the  appendicitis ;  and  that  a  second- 
ary portal  phlebitis  may  seem  to  be  the  primary  lesion. 

Chronic  Peritonitis  with  Adhesions. 

This  is  a  chronic  productive  inflammation  without  exudation, 
which  involves  more  or  less  of  the  peritoneum,  and  results  in  the 
formation  of  new  connective  tissue  in  the  shape  of  adhesions. 

Causes. — Such  a  chronic  peritonitis  may  follow  an  acute  peri- 
tonitis ;  it  may  be  due  to  abscesses  in  the  abdominal  cavity  or 
in  the  wall  of  the  abdomen  ;  it  may  be  a  primary  chronic  inflam- 
mation without  discoverable  cause. 

Lesions. — We  find  after  death  threads  and  membranes  of  con- 
nective tissue  which  join  together  adjacent  surfaces  of  perito- 
neum in  a  great  variety  of  ways.  The  cases  vary  as  to  the  num- 
ber and  extent  of  the  adhesions. 

Symptoms. — With  but  few  adhesions  there  are  no  symptoms, 
or  only  occasional  attacks  of  pain,  apparently  brought  on  by 
flatulence. 

With  extensive  adhesions,  chronic  catarrhal  inflammation  of 
the  stomach  and  bowels,  with  their  characteristic  symptoms,  are 
established.  Often  we  can  appreciate  by  palpation  that  the  in- 
testines are  matted  together.  The  patients  lose  flesh  and 
strength,  but  seem  to  die  rather  from  some  intercurrent  disease 
than  from  the  peritonitis.  In  such  patients  there  is  always  dan- 
ger of  strangulation  of  the  intestine. 


374  PERITONITIS. 

The  treatment  is  directed  principally  to  the  disturbance  of  the 
functions  of  the  stomach  and  bowels. 

Chronic  Peritonitis  with  the  Production  of  Serum,  Fibrin, 
Pus,  AND  Connective  Tissue. 

This  is  a  chronic  productive  inflammation  with  exudation, 
which  involves  a  considerable  part  of  the  peritoneum,  and  results 
in  the  formation  of  serum,  fibrin,  and  pus,  and  of  new  connective 
tissue  in  the  form  of  adhesions. 

Causes. — It  follows  acute  peritonitis  ;  it  is  caused  by  diseases 
of  the  uterus  and  its  appendages,  by  localized  peritonitis,  and  by 
abscesses  in  the  peritoneal  cavity.  It  may  begin  as  a  chronic 
inflammation  without  discoverable  cause. 

Lesions. — The  adhesions  mat  together  the  coils  of  intestine 
and  divide  up  the  abdominal  cavity  in  a  variety  of  irregular  ways. 
The  free  surface  of  the  peritoneum  is  coated  with  fibrin  and  pus. 
Purulent  serum,  in  small  or  large  quantities,  occupies  the  perito- 
neal cavity  or  is  shut  in  by  adhesions. 

Symptoms. — If  the  chronic  peritonitis  is  secondary,  there  is  the 
previous  history  of  the  localized  peritonitis  or  abscess.  If  it  is 
primary,  the  invasion  is  slow  and  obscure. 

The  patients  suffer  from  more  or  less  abdominal  oain  and 
tenderness. 

The  physical  signs  vary  with  the  extent  and  distribution  of 
the  adhesions  and  the  quantity  of  serum. 

Constipation  or  diarrhoea  are  often  present,  but  it  is  possible 
for  the  bowels  to  move  regularly  throughout  the  disease.  In 
most  patients  there  is  an  irregular  febrile  movement,  but  there 
may  be  no  rise  of  temperature  for  months. 

The  heart's  action  and  pulse  are  rapid  and  feeble. 

There  are  symptoms  of  gastric  dyspepsia,  and  the  stomach 
becomes  less  and  less  able  to  digest  and  retain  food. 

The  patients  steadily  lose  flesh  and  strength,  and  die  ema- 
ciated and  feeble  after  a  protracted  illness. 

Chronic  Peritonitis  with  Thickening  oe  the  Peritoneum. 

This  is  a  chronic  productive  inflammation  with  exudation, 
which  involves  the  greater  part  of  the  peritoneum,  and  results  in 
a  diffuse  thickening  of  the  peritoneum  and  an  accumulation  of 
serum  in  its  cavity. 


PERITONITIS.  375 

Ca/ises.— This  form  of  peritonitis  seems  to  be  a  primary  in- 
flammation, and  to  belong  to  adult  life,  but  we  are  entirely  igno- 
rant as  to  its  causes. 

Zeswns.—We  find  after  death  a  general  diffuse  growth  of 
dense  connective  tissue,  forming  a  thickening  of  the  parietal  and 
visceral  peritoneum.  There  may  also  be  more  or  less  serum  in 
the  peritoneal  cavity. 

Symptoms. — The  only  physical  signs  are  those  belonging  to 
the  presence  of  fluid  in  the  abdominal  cavity. 

The  symptoms  depend  largely  upon  the  interference  with  the 
functions  of  the  stomach,  intestines,  and  liver. 

The  thickening  of  the  peritoneal  coat  of  the  stomach  is  at- 
tended with  contraction  of  the  organ  and  catarrhal  inflamma- 
tion of  its  mucous  membrane.  The  patients  suffer  from  pain, 
vomiting,  and  failure  of  gastric  digestion. 

The  intestines  become  the  seat  of  a  chronic  catarrhal  ente- 
ritis, with  disturbance  of  the  functions  of  the  small  and  large  in- 
testine. 

The  thickening  of  the  capsule  of  the  liver  diminishes  the  size 
of  this  organ,  interferes  with  the  portal  circulation,  and  pro- 
duces ascites. 

The  patients  gradually  lose  flesh  and  strength,  and  die. 

Tubercular  Peritonitis. 

The  peritoneum  is  rather  frequently  the  seat  of  localized  tu- 
bercular inflammation.  As  is  usually  the  case,  the  growth  of 
tubercle  bacilli  and  formation  of  tubercle  tissue  are  associated 
with  other  forms  of  inflammation. 

Lesions. — The  tubercle  tissue  is  in  the  form  of  miliary  tuber- 
cles, of  large  cheesy  masses,  or  of  flat  plates.  The  associated  in- 
flammation results  in  the  production  of  serum,  of  fibrin,  or  of 
connective  tissue  in  a  variety  of  v/ays. 

1.  The  peritoneum  is  thickly  studded  with  miliary  tubercles, 
coated  with  a  little  fibrin,  and  there  is  a  little  serum  in  the  peri- 
toneal cavity. 

2.  With  miliary  tubercles  or  cheesy  nodules  there  is  a  very 
large  exudation  of  serum,  which  distends  the  abdomen  ;  or  of 
fibrin,  which  fills  in  all  the  interstices  between  the  abdominal 
viscera  and  also  distends  the  abomen. 

3.  With  miliary  tubercles,  or  with   cheesy  masses,  there  is    a 


376  PERITONITIS. 

considerable  growth  of  new  connective  tissue.  The  new  tissue 
maybe  confined  to  the  omentum,  and  convert  this  into  a  hard 
tumor  of  some  size. 

Or  it  may  simply  form  adhesions  between  the  coils  of  intes- 
tine so  that  these  become  firmly  matted  together. 

Or  the  adhesions  may  shut  in  collections  of  serum,  or  of  pus, 
which  may  reach  a  considerable  size  and  resemble  cysts. 

Tubercular  pleurisy,  and  tubercular  inflammation  of  the 
Fallopian  tubes,  are  often  associated  with  tubercular  peritonitis. 

Causes. — The  disease  occurs  both  in  children  and  in  adults. 
It  is  said  to  be  most  frequent  in  persons  between  twenty  and 
forty  years  of  age.  It  is  most  frequently  a  primary  inflammation, 
but  may  be  secondary  to  tuberculosis  of  other  parts  of  the  body. 

Symptoms. — Few  diseases  present  a  greater  variety  in  the  de- 
velopment of  the  lesions  and  the  manifestation  of  the  symptoms 
than  does  tubercular  peritonitis. 

1.  The  latent  form  of  the  disease.  There  are  cases  in  which 
not  only  are  there  no  abdominal  symptoms,  but  no  apparent 
change  in  the  general  health.  Operations  for  strangulated  her- 
nia and  ovarian  tumors  from  time  to  time  disclose  an  extensive 
tubercular  peritonitis  of  which  no  symptoms  had  been  given. 
In  the  same  way  the  disease  may  be  discovered  in  autopsies  on 
persons  dying  from  other  diseases. 

There  are  cases  in  which  there  are  no  abdominal  symptoms, 
but  yet  the  general  health  suffers  and  death  may  follow.  The 
appearance  and  feeling  of  the  abdomen  are  natural.  There  is 
no  evidence  of  fluid  or  of  adhesions,  no  pain,  no  tenderness,  no 
distention.  The  liver  may  be  small  and  the  spleen  large.  But 
there  are  a  variety  of  rather  indefinite  symptoms.  Loss  of  ap- 
petite, nausea,  vomiting,  constipation,  diarrhoea,  blood  in  the 
stools,  a  little  jaundice,  a  rapid  heart,  an  irregular  fever  with 
evening  exacerbations,  gradual  loss  of  flesh  and  strength,  some- 
times a  complicating  meningitis,  or  pericarditis,  or  pleurisy. 
The  course  of  the  disease  is  slow,  with  long  intervals  of  im- 
provement. Recovery  seems  to  be  possible,  but  death  is  the 
rule. 

2.  The  disease  may  behave  at  first  like  an  acute  peritonitis, 
with  a  sudden  rise  of  temperature,  vomiting,  tympanites,  and 
pain  and  tenderness  over  the  abdomen.  After  some  days  these 
acute  symptoms  subside  and  the  patients  go  on  with  a  chronic 
peritonitis. 


PERITONITIS.  377 

3.  The  patients  behave  as  if  they  had  a  chronic  peritonitis 
with  a  large  exudation  of  serum.  The  abdomen  becomes  largely 
distended  by  turbid  serum,  and  is  the  seat  of  more  or  less  pain 
and  discomfort.  There  is  a  slight  and  irregular  rise  of  tempera- 
ture. The  patients  vomit  occasionally,  the  bowels  are  irregular, 
there  is  a  gradual  loss  of  flesh  and  strength. 

4.  In  a  tubercular  peritonitis  with  an  excessive  production  of 
fibrin  the  rational  symptoms  are  the  same  as  when  there  is  an  ex- 
cessive production  of  serum.  The  abdomen  is  large,  painful, 
and  tender,  but  the  physical  signs  are  not  those  of  fluid  in  the 
abdominal  cavity. 

5.  The  coils  of  intestine  are  matted  together  by  connective- 
tissue  adhesions,  with  but  little  or  no  fluid  in  the  abdominal 
cavity.  These  are  very  chronic  cases  with  little  or  no  fever,  and 
with  symptoms  largely  referable  to  the  stomach  and  intestines. 
They  have  loss  of  appetite,  nausea,  pain,  vomiting,  flatulence, 
diarrhoea,  or  constipation,  and  gradual  loss  of  flesh  and  strength. 
The  abdomen  may  be  tympanitic  or  retracted;  sometimes  we  can 
feel  through  the  anterior  abdominal  wall  the  tumor-like  mass 
made  up  of  the  adherent  coils  of  intestine. 

6.  The  tubercular  inflammation  involves  chiefly  the  omentum. 
This  gradually  becomes  thickened  and  rolled  together  until  it 
forms  a  long,  hard  tumor  running  across  the  upper  part  of  the 
abdomen.  The  clinical  history  of  these  patients  is  simply  that 
they  have  a  hard  tumor  in  the  upper  part  of  the  abdomen,  with 
gradual  loss  of  flesh  and  strength. 

7.  A  sero-fibrinous  or  purulent  exudation  is  sacculated  by  ad- 
hesions formed  between  the  intestinal  coils,  the  parietal  perito- 
neum, the  mesentery,  and  the  abdominal  or  the  pelvic  organs. 
The  rest  of  the  peritoneum  is  altered  by  chronic  inflammation. 
The  collections  of  fluid  occupy  the  entire  anterior  portion  of  the 
peritoneal  cavity,  or  they  are  smaller  and  situated  either  in  the 
middle  of  the  abdomen  or  on  either  side.  Such  collections  of 
fluid,  when  felt  through  the  anterior  abdominal  wall,  feel  like 
tumors  or  cysts.  They  have  frequently  been  mistaken  for 
ovarian  cysts. 

These  cases  vary  as  to  whether  the  symptoms  of  chronic  peri- 
tonitis or  those  of  an  abdominal  tumor  predominate. 

There  may  be  an  irregular  fever,  vomiting,  constipation  or 
diarrhoea,  abdominal  pain  and  tenderness,  gradual  emaciation, 
the  patient  always  in  bed,  and  getting  steadily  worse.     Or  the 


378  PERITONITIS. 

constitutional  symptoms  are  rather  those  of  a  malignant  growth 
with  a  well-marked  abdominal  tumor.  Or  with  a  well-marked 
tumor  the  patients  may  continue  to  be  well  nourished. 

The  physical  signs  are  those  of  one  or  more  cystic  or  semi- 
solid tumors  in  the  abdomen.  The  tumors  are  most  frequently 
mistaken  for  ovarian  cysts,  or  for  malignant  new-growths. 

Treatment. — There  seems  to  be  good  reason  to  believe  that 
in  some  cases  of  tubercular  peritonitis  the  inflammation  runs  its 
course,  subsides,  and  the  patients  recover,  but  with  permanent 
peritoneal  adhesions. 

In  cases  of  tubercular  peritonitis  which  have  only  lasted  for 
a  moderate  length  of  time,  with  a  large  serous  effusion  and  not  a 
great  many  adhesions,  a  cure  may  be  effected  by  making  a  free 
incision  through  the  anterior  abdominal  wall,  allowing  the  fluid 
to  escape,  and  then  closing  the  wound.  In  the  older  cases,  with 
extensive  and  firm  adhesions,  operative  interference  is  but  of 
litte  value. 

Apart  from  operation,  the  treatment  consists  in  feeding  the 
patients  and  relieving  symptoms. 

Carcinoma  of  the  Peritoneum. 

Lesions. — Primary  carcinoma  of  the  peritoneum  occurs  in  the 
form  of  colloid  cancer,  or  of  hard  nodules  composed  of  a  con- 
nective-tissue stroma  enclosing  cavities  which  contain  cells  of 
epithelial  type. 

The  growths  are  regularly  multiple,  and  grow  in  many  differ- 
ent parts  of  the  peritoneum.  The  tumors  may  all  be  of  small 
size,  or  some  of  them  reach  a  diameter  of  several  inches  ;  or,  in 
the  case  of  colloid  cancer,  very  large  tumors  may  be  formed. 

With  the  new-growth  there  is  a  production  of  serum,  or  of 
fibrin,  or  of  connective-tissue  adhesions,  or  a  general  thickening 
of  the  peritoneum. 

Causes. — The  disease  belongs  to  persons  over  forty  years  of  age. 

Symptoms. — The  physical  signs  depend  upon  the  size  of  the 
tumors,  the  serum,  and  the  adhesions. 

The  invasion  of  the  symptoms  is  slow  and  gradual,  and  some 
time  elapses  before  the  patients  seem  to  be  seriously  ill. 

Disturbances  of  the  stomach  and  intestines,  more  or  less  pain, 
and  constant  loss  of  flesh  and  strength  are  the  prominent  symp- 
toms. 


RHEUMATISM. 


It  is  customary  to  speak  of  acute  articular  rheumatism,  suba- 
cute rheumatism,  chronic  rheumatism,  muscular  rheumatism, 
gonorrhoeal  rheumatism,  rheumatoid  arthritis,  scarlatinal  rheu- 
matism, and  puerperal  rheumatism  as  if  they  were  all  varieties 
of  one  and  the  same  disease.  We  are,  however,  not  sufficiently 
acquainted  with  the  nature  of  most  of  these  so-called  rheuma- 
tisms to  tell  how  nearly  they  are  or  are  not  related  to  each  other. 

Acute  Articular  Rheumatism. 

This  is  an  acute,  general  disease  of  which  the  characteristic 
lesion  is  an  inflammation  of  the  joints  and  of  some  of  the  con- 
nective-tissue membranes. 

Lesio7is. — The  joint  lesion  is  an  acute  exudative  inflammation 
of  the  synovial  membranes  with  congestion  and  an  exudation  of 
serum,  but  only  rarely  a  production  of  pus  or  fibrin. 

Of  the  connective-tissue  membranes  the  pericardium  and  the 
endocardium  are  the  ones  most  frequently  inflamed  ;  less  often 
the  pia  mater,  the  pleura,  and  the  peritoneum. 

There  may  also  be  inflammations  of  the  iris,  the  pharynx  and 
tonsils,  and  the  lungs. 

Causes. — The  disease  is  most  common  in  the  temperate  zones, 
but  is  also  observed  in  both  cold  and  warm  climates.  The  at- 
tacks are  not  confined  to  any  one  season  of  the  year. 

The  time  of  greatest  liability  to  the  disease  is  between  the 
ages  of  ten  and  thirty  years.  There  seems  to  be  both  an  heredi- 
tary and  a  personal  predisposition  to  the  disease,  and  the  same 
individual  often  suffers  from  several  attacks.  The  strong  and 
vigorous,  and  the  feeble  and  debilitated,  seem  to  be  equally 
liable  to  the  disease.  Exposure  to  cold  and  wet  may  often  act 
as  excitinsf  causes. 


38o  RHEUMATISM. 

Symptoms. — The  symptoms  of  the  disease  may  begin  in  several 
different  ways. 

1.  For  a  few  hours,  or  for  several  days,  the  patients  complain 
of  general  malaise,  headache,  irregular  chills,  a  little  fever,  irri- 
tability, sleeplessness,  a  coated  tongue,  no  appetite,  urine  loaded 
with  urates,  and  irregular  pains  about  the  joints. 

2.  There  are  pain  and  stiffness  of  one  or  more  joints,  gradu- 
ally increasing,  and   followed,  after  some  hours  or  days,  by  fever. 

3.  The  invasion  is  sudden — chills,  a  rapid  rise  of  temperature, 
and  inflammation  of  one  or  more  joints. 

When  the  disease  is  established  there  is  a  febrile  movement, 
the  pulse  is  full  and  rapid,  the  skin  is  hot  and  dry  or  bathed  in 
acid  perspiration,  the  tongue  is  coated,  nausea  and  vomiting  are 
often  present,  the  bowels  are  constipated,  the  urine  is  diminished 
in  quantity  and  loaded  with  urates,  the  intelligence  is  clear,  but 
restlessness  and  sleeplessness  are  apt  to  be  marked  features. 

One  or  more  joints  are  inflamed,  swollen,  painful,  and  tender. 
The  cases  vary  as  to  the  severity  of  the  pain,  the  intensity  of  the 
synovitis,  the  number  of  joints  inflamed,  and  the  way  in  which 
one  joint  after  another  is  involved. 

Complications  :  i.  Hyperpyrexia. — The  disease  begins  mildly 
or  severely.  It  runs  its  ordinary  course  for  a  few  days  and  then 
the  temperature  rises  rapidly,  while  the  inflammation  of  the 
joints  subsides.  The  sweating  ceases,  the  tongue  becomes  brown 
and  dry,  the  pulse  is  rapid  and  feeble,  the  breathing  is  rapid,  the 
patients  suffer  from  restlessness,  sleeplessness,  headache,  hyper- 
sesthesia  of  the  skin,  muscular  tvvitchings,  general  convulsions, 
delirium,  and  coma.     They  usually  die  in  a  few  days. 

2.  Pericarditis  and  Endocarditis. — These  inflammations  are 
especially  common  in  young  persons.  They  occur  both  in  mild 
and  severe  cases.  They  usually  follow  the  joint  lesion,  but  may 
precede  it,  or  even  occur  without  it. 

If  a  pericarditis  is  developed  the  temperature  rises,  the  pulse 
is  more  rapid,  there  is  praecordial  pain,  and  mere  or  less  dyspnoea. 
The  physical  signs  vary  with  the  presence  of  fibrin  alone,  or  of 
both  fibrin  and  serum. 

Some  of  the  cases  recover  completely,  others  recover  but 
with  permanent  pericardial  adhesions,  while  still  others  die  from 
the  pericarditis. 

If  an  endocarditis  is  developed  there  is  a  rise  in  the  tem- 
perature,  the   patients  look   worse,  the   heart's  action    becomes 


RHEUMATISM.  38 1 

rapid,  tumultuous,  or  irregular  ;  after  one  or  two  days  a  valvular 
murmur  can  be  heard.  After  the  patients  have  recovered,  the 
valves  which  have  been  inflamed  are  left  permanently  damaged. 

3.  Complicating  inflammations  of  the  pia  mater,  pleura,  or 
lung  give  their  ordinary  symptoms. 

Duration. — The  regular  duration  of  an  attack  of  acute  articular 
rheumatism  seems  to  be  three  weeks,  but  the  disease  may  run  its 
course  w^ithin  a  few  days  ;  it  may  last  for  months,  or  its  course 
may  be  protracted  by  relapses. 

Terminations. — Some  of  the  patients  recover  completely,  and 
never  have  another  attack  of  the  disease. 

Others  suffer  from  a  number  of  attacks  at  short  or  long  in- 
tervals. 

In  some  the  rheumatism  runs  its  course,  but  one  joint  remains 
inflamed. 

In  some  the  convalescence  is  unusually  prolonged,  the  pa- 
tients remain  feeble  and  anaemic,  with  stiff  and  tender  joints. 

In  a  considerable  number  the  pericarditis  or  endocarditis  lays 
the  foundation  of  serious  cardiac  disease. 

Death  in  the  course  of  acute  rheumatism  is  usually  due  to 
hyperpyrexia,  pericarditis,  endocarditis,  pneumonia,  pleurisy,  or 
meningitis. 

Treatment. — i.  Of  mild  cases  with  inflammation  of  only  one 
joint.  These  can  often  be  very  well  managed  by  the  application 
of  continuous  cold  to  the  inflamed  joint,  with  small  doses  of 
opium. 

2.  Of  the  regular  well-marked  cases.  The  majority  of  these 
are  to  be  treated  by  the  salicylate  of  soda,  10  to  20  grains  every 
two  hours  ;  the  oil  of  wintergreen,  20  minims  every  two  hours  ; 
or  salicin,  10  to  20  grains  every  two  hours.  The  dose  of  these 
medicines  is  diminished  as  the  disease  subsides.  The  favorable 
effect  of  these  remedies  is  seen  in  the  improvement  of  the  con- 
stitutional symptoms  and  the  inflammation  of  the  joints.  They 
do  not  seem  to  shorten  the  duration  of  the  disease  or  lessen 
the  liability  to  complicating  inflammations. 

Some  patients,  however,  are  not  at  all  benefited  by  the  use  of 
these  drugs  ;  others  get  their  poisonous  instead  of  their  medicinal 
effects. 

There  are  fat,  florid,  overfed  patients  who,  when  they  have 
an  attack  of  acute  rheumatism,  are  best  treated  by  alkalies. 

The  patients  are  given   3  ij.  of  bicarbonate  of  potash  in  solu- 


382  RHEUMATISM. 

tion,  with  3  j.  of  lemon-juice,  every  three  hours  for  four  days. 
After  this  they  take  30  grains  of  bicarbonate  of  potash  with  3 
grains  of  quinine  dissolved  in  lemon-juice  three  times  a  day. 
The  bowels  are  to  be  kept  open  every  day. 

There  is  a  group  of  cases  characterized  by  excessive  pain  in 
the  joints,  without  very  much  inflammation  of  them.  The  best 
remedies  for  these  patients  are  phenacetine  in  5-grain  doses 
every  two  hours,  antipyrine  in  10-  to  20-grain  doses  every  two 
hours,  or  salol  in  5-grain  doses  every  two  hours. 

There  are  feeble  and  anaemic  patients  who,  when  they  have 
an  attack  of  acute  rheumatism,  are  not  benefited  by  any  of  the 
drugs  which  have  been  mentioned.  They  have  to  be  treated  by 
the  iodide  of  potash,  iron,  quinine,  and  cod-liver  oil. 

Patients  with  the  gouty  diathesis,  when  they  have  acute  rheu- 
matism, often  improve  more  rapidly  if  we  combine  colchicum 
with  some  of  the  drugs  already  mentioned. 

Cases  complicated  by  hyperpyrexia  are  to  be  treated  by  cold 
baths. 

If  the  patients  recover  from  their  rheumatism  but  one  joint 
remains  inflamed  ;  this  joint  is  to  be  treated  first  by  the  applica- 
tion of  cold,  then  by  rest  and  pressure,  and  then  by  massage  and 
passive  motion. 

The  protracted  convalescence  is  to  be  treated  by  change  of 
climate,  iron,  quinine,  and  strychnine. 

Subacute  Rheumatism. 

In  this  form  of  rheumatism  the  invasion  of  the  symptoms  is 
gradual.  The  patients  lose  their  appetite,  the  bowels  are  consti- 
pated, the  tongue  is  coated,  they  become  anaemic,  feeble,  and 
emaciated.  A  number  of  the  joints  are  moderately  inflamed,  a 
little  swollen,  somewhat  painful  and  tender.  There  may  be  a 
complicating  endocarditis. 

The  disease  is  apt  to  last  for  a  long  time  and  to  recur  a  num- 
ber of  times  in  the  same  patient.  Its  treatment  is  often  very  un- 
satisfactory. 

We  employ  the  salicylate  of  soda,  antipyrine,  phenacetine, 
iron,  quinine,  strychnine,  the  alkaline  and  sulphur  mineral 
waters  and  baths,  massage,  and  change  of  climate. 


RHEUMATISM.  383 


Muscular  Rheumatism. 

This  is  an  affection  of  the  muscles,  apparently  of  inflamma- 
tory character,  which  causes  them  to  become  painful  and  tender. 
The  muscles  most  frequently  affected  are  those  of  the  shoulder, 
neck,  and  back. 

Causes. — The  disease  is  especially  common  in  adult  life.  The 
same  person  often  suffers  from  a  number  of  attacks.  There  is 
frequently  a  distinct  history  of  exposiu'e  of  the  affected  muscles 
to  a  draught  of  cold  air.  Similar  conditions  of  the  muscles  are 
developed  after  over-exertion  and  as  a  complication  of  scarlet 
fever. 

Symptojiis. —  The  disease  occurs  in  different  degrees  of  severity. 

1.  One  or  more  muscles,  within  a  few  hours,  become  painful 
on  motion.  If  the  muscles  are  not  moved  there  is  no  pain. 
There  is  no  constitutional  disturbance,  and  the  patients  continue 
to  feel  well.  The  muscles  remain  in  this  condition  for  days  or 
weeks.     Hardly  any  treatment  is  necessary. 

2.  There  is  not  only  pain  on  motion  in  the  affected  muscles, 
but  also  pain  when  they  are  at  rest,  and  this  pain  comes  on  in 
paroxysms  which  are  exceedingly  severe. 

3.  A  large  number  of  the  muscles  of  the  back  are  involved, 
the  pain  is  severe,  there  is  some  rise  of  temperature,  and  the  pa- 
tients feel  sick. 

These  more  severe  cases  require  treatment.  We  use  as  local 
applications  mustard-plasters,  hot  fomentations,  and  the  faradic 
current.  The  most  efficient  drugs  seem  to  be  phenacetine,  anti- 
pyrine,  or  the  iodide  of  potash  and  gelseminum  given  together. 

GONORRHCEAL    RHEUMATISM. 

This  name  is  given  to  an  inflammation  of  the  joints  and  the 
tissues  about  them,  which  has  nothing  to  do  with  real  rheuma- 
tism, but  is  a  specific  inflammation  accompanied  with  the  growth 
of  the  same  bacteria  which  are  found  with  the  specific  urethritis. 
There  are  two  varieties  of  gonorrhoeal  rheumatism  : 
I.  There  is  an  inflammation  of  the  tissues  around  the  joints, 
with  diffuse  swelling,  pain,  tenderness,  and  redness  of  the  skin. 
The  ankle-joints  are  those  most  frequently  involved,  but  the 
wrists  and  the  other  joints  may  be  affected  in  the  same  way. 


384  RHEUMATISM. 

The  inflammation  is  of  acute  or  subacute  character,  and  is 
apt  to  be  long  and  tedious.  It  terminates  in  complete  recovery, 
in  stiffening  of  the  joints,  or  in  suppuration. 

Treat7nent. — The  inflammation  is  to  be  treated  first  by  the  con- 
tinuous application  of  cold,  then  by  rest  and  pressure,  and  finally 
by  massage  and  passive  motion. 

2.  There  is  a  subacute  synovitis,  which  involves  most  fre- 
quently one  of  the  knee-joints.  The  joint  is  distended  with 
serum,  the  inflammation  may  become  purulent,  and  end  in  de- 
struction of  the  joint. 

Treatment. — Extension,  pressure,  or  the  opening  and  scraping 
of  the  joint  are  the  methods  of  treatment. 

Chronic  Rheumatism. 

Lesions. — -A  chronic  inflammation  begins  in  the  synovial  mem- 
brane of  one  or  more  joints.  The  inflamed  membrane  becomes 
dense  and  thick,  the  fluid  within  the  synovial  sac  is  usuallv 
scanty  and  grumous,  sometimes  abundant  and  serous.  The  in- 
flammation may  extend  to  the  capsules  and  ligaments  of  the 
joints,  the  articular  cartilages,  and  the  bones. 

As  complicating  lesions  we  find  chronic  endocarditis,  chronic 
endarteritis,  pulmonary  emphysema  and  bronchitis,  and  chronic 
nephritis. 

Causes. — The  disease  belongs  to  adult  life  and  to  old  age.  It 
is  especially  common  among  the  poor  and  among  persons  who 
are  constantly  exposed  to  all  sorts  of  weather.  In  some  persons 
the  course  of  the  chronic  rheumatism  is  varied  by  attacks  of 
acute  rheumatism. 

Symptoms. — The  symptoms  are  principally  the  local  symptoms 
of  the  inflamed  joints.  But  from  time  to  time  there  may  be  a 
little  rise  of  temperature,  and,  after  a  while,  digestive  disturb- 
ances, loss  of  nutrition,  and  the  symptoms  belonging  to  the  com- 
plicating lesions  are  developed. 

The  inflammation  begins  in  one  or  more  joints,  often  those 
of  the  hands  and  feet,  continuing  in  these  joints  and  then  gradu- 
ally extends  to  others,  until  in  the  worst  cases  nearly  all  the 
joints  in  the  body  are  involved.  The  affected  joints  are  tender 
and  painful,  swollen,  sometimes  fluctuating,  sometimes  stiff,  some- 
times creaking.  The  course  of  the  inflammation  is  slow,  with  re- 
missions and  exacerbations. 


RHEUMATISM.  '  385 

The  patients  vary  as  to  the  position  and  number  of  the  joints 
inflamed,  and  as  to  the  extent  of  the  changes  in  the  joints. 

The  prognosis  is  always  bad,  but  yet  in  some  patients  the 
disease  never  cripples  them  completely. 

The  only  efficient  treatment  consists  in  the  use  of  the  natural 
mineral  waters  taken  internally  and  as  baths.  The  best  waters 
seem  to  be  those  of  Sharon,  Richfield,  Virginia,  North  Carolina, 
Arkansas,  Wiesbaden,  and  Aix-les-Bains. 

Arthritis  Deformans. 

Synonyms. — Rheumatoid  Arthritis,  Rheumatic  Gout,  Rhuma- 
tisme  Noueux,  Chronic  Rheumatism. 

Lesions. — There  is  a  chronic  inflammation  of  the  joints  which 
from  the  outset,  involves  the  cartilages,  bones,  and  synovial 
membranes — a  chronic  pan-arthritis.  The  articular  ends  of  the 
bones  become  thickened,  flattened,  and  deformed  by  outgrowths 
of  bone  ;  the  cartilages  are  softened,  eroded,  and  destroyed  ;  the 
synovial  membranes  are  thickened.  The  joints  become  stiffened, 
deformed,  sometimes  dislocated. 

Cajises. — The  cases  in  which  the  joints  of  the  hands  and  feet 
are  affected  are  most  common  in  adult  females  belonging  to  the 
poorer  classes.  The  form  which  involves  the  larger  joints  is 
most  common  in  adult  males.  It  is,  however,  possible  for  either 
form  of  the  disease  to  occur  in  children. 

Syrnptoms. — The  arthritis  comes  on  slowly  and  gradually.  Usu- 
ally the  joints  of  the  hands  and  feet  are  first  involved,  but  any 
one  of  the  larger  joints  may  be  the  first  affected.  The  natural 
tendency  of  the  disease,  as  it  advances,  is  to  attack  one  joint  after 
another. 

The  inflamed  joints  become  painful  and  tender  ;  then  gradu- 
ally stiffened,  swollen,  deformed,  and  dislocated.  The  corre- 
sponding muscles  become  contractured  and  atrophied.  From 
time  to  time  there  may  be  exacerbations  of  the  arthritis,  with  a 
rise  of  temperature. 

The  course  of  the  disease  is  slow,  but  progressive.  The  pa- 
tients become  more  and  more  helpless  ;  digestive  disturbances 
are  developed  ;  loss  of  flesh  and  strength  and  anaemia  become 
more  and  more  marked.  The  condition  of  the  patient  is  ren- 
dered still  worse  by  complicating  lesions  :  Bronchitis,  chronic 
nephritis,  emphysema,  and  chronic  endarteritis. 


386  GOUT. 

The  treatment  is  very  unsatisfactory.  The  only  thing  that 
seems  to  be  of  any  service  is  the  use  of  the  natural  mineral 
waters  and  baths,  or  the  continued  use  of  the  iodide  of  potash. 

Gout. 

It  is  customary  to  describe  acute  gout,  chronic  gout,  and  irreg- 
ular gout. 

Our  notions  concerning  the  true  nature  of  gout  can  hardly  be 
considered  as  settled.  But  at  the  present  time  the  views  of  Gar- 
rod  are  accepted  as  a  probable  theory. 

Gouty  inflammations  of  the  joints  are  caused  by  the  deposi- 
tion of  urate  of  soda  in  the  articular  cartilages.  The  functions 
of  the  kidneys  are  disturbed,  and,  after  a  time,  they  become  the 
seat  of  a  chronic  diffuse  nephritis  with  little  or  no  exudation. 
During  an  attack  of  gout  the  blood  becomes  less  alkaline,  or 
there  is  an  increase  of  uric  acid  in  it,  or  there  is  a  diminished  ex- 
cretion of  uric  acid  by  the  kidneys. 

Lesions.  —The  blood  before  and  during  an  attack  of  gout  con- 
tains an  increased  quantity  of  urate  of  soda.  In  chronic  and  irreg- 
ular gout  there  is  always  an  increase  of  urate  of  soda  in  the 
blood. 

In  the  joints  there  is  an  acute  or  chronic  inflammation,  with 
a  deposition  of  urate  of  soda  in.  the  articular  cartilages.  De- 
posits of  urate  of  soda  are  also  formed  in  the  synovial  membranes, 
the  ligaments,  the  bursae,  the  sheaths  of  tendons  and  of  muscles, 
the  cartilages  of  the  ears,  and  under  the  skin. 

The  kidneys  become  the  seat  of  a  chronic  nephritis  with  little 
or  no  exudation,  but  with  a  very  large  production  of  interstitial 
connective  tissue. 

Complicating  lesions  are  of  very  frequent  occurrence  :  Bron- 
chitis, emphysema,  endocarditis,  endarteritis,  eczema,  and  chronic 
catarrhal  gastritis. 

Causes. — The  hereditary  disposition  to  the  disease  is  very 
marked.  The  gouty  disposition  may  be  acquired  by  the  excessive 
use  of  nitrogenized  food,  of  strong  wines,  and  of  malt  liquors  ; 
by  a  sedentary  life  ;  by  lead-poisoning  ;  and  by  insufficient  nour- 
ishment. The  disease  is  especially  prevalent  in  temperate  and 
damp  climates. 

As  exciting  causes  of  attacks  of  gout  we  recognize  :  Certain 
articles  of  food  and  drink,  exposure  to  the  weather,  and  injuries. 


GOUT.  387 

Symptoms  :  i.  Of  Acute  Gout. — An  attack  of  acute  gout  is  apt 
to  come  on  during  the  night.  There  is  sudden  pain  in  one  of 
the  great-toe  joints,  chilliness,  fever,  restlessness,  and  sleepless- 
ness. The  next  day  the  joint  is  swollen,  the  skin  about  it  red, 
tense,  and  shining.  The  joint  is  extremely  tender  and  painful. 
The  urine  is  scanty,  high-colored,  and  acid.  Before  and  during 
the  attack  the  quantity  of  uric  acid  in  the  urine  is  diminished  ; 
after  the  attack  it  is  increased.  Such  an  attack  lasts  for  days  or 
weeks. 

The  first  attack  is  usually,  but  not  always,  without  premoni- 
tion. The  subsequent  attacks  are  preceded  by  indigestion,  con- 
stipation, flatulence,  palpitation  of  the  heart,  broncliitis,  irrita- 
bility of  temper.  The  urine  is  scanty  and  high-colored,  or  abun- 
dant and  pale. 

One  of  the  great-toe  joints  is  the  joint  most  frequently  in- 
flamed ;  next  in  order  of  frequency  are  the  ankle,  the  instep,  the 
outer  side  of  the  foot,  the  knee  ;  or  several  joints  may  be  in- 
flamed at  the  same  time.  After  the  inflammation  has  subsided 
the  joint  returns  to  its  natural  condition,  or  may  be  left  a  little 
stiff.  The  intensity  of  the  inflammation  of  the  joint  varies  very 
much  in  the  different  cases. 

The  height  of  the  temperature  is  usually  in  proportion  to  the 
severity  of  the  joint  lesion. 

Instead  of  the  regular  attacks  of  acute  gout  with  inflamma- 
tion of  the  joints,  there  may  be  acute  attacks  with  little  or  no 
joint  trouble,  but  with  great  prostration  and  symptoms  referable 
to  the  stomach,  heart,  brain,  or  lungs. 

In  the  stomach  there  is  intense  pain,  nausea,  and  vomiting. 

If  the  heart  is  affected  there  are  pain,  oppression,  palpitation, 
feeble  heart  action,  and  sometimes  syncope. 

The  brain  symptoms  are  severe  headache  and  delirium. 

The  pulmonary  symptom  is  spasmodic  asthma. 

It  is  possible  for  a  person  to  have  only  one  attack  of  acute 
gout,  but  usually  the  attacks  are  repeated,  and  often  become 
more  frequent  as  the  patient  grows  older. 

Treatment. — During  the  attack  the  patient  is  to  be  kept  quiet, 
on  a  light  diet,  with  perhaps  some  opium  to  relieve  the  pain. 
The  bowels  are  to  be  moved  freely  every  day,  and  considerable 
quantities  of  fluid  are  to  be  drunk.  The  inflamed  joint  must  be 
kept  quiet  and  free  from  pressure. 

The  most  efficient  drug  is  colchicum,  the  wine  of  the  root,  or 


388  GOUT. 

the  acetous  extract.  The  dose  at  first  is  considerable,  thirty 
minims  to  a  drachm  of  the  wine,  one  to  two  grains  of  the  ex- 
tract ;  later,  these  doses  are  diminished.  The  colchicum  is 
usually  combined  with  the  salicylate  of  soda  or  the  iodide  of 
potash.  The  objection  to  the  use  of  colchicum  is  its  liability  to 
produce  vomiting  and  diarrhoea.  Instead  of  colchicum,  phenace- 
tine  in  5-grain  doses  every  two  hours  will  sometimes  answer  very 
well. 

To  prevent  the  recurrence  of  attacks  the  diet  must  be  re- 
stricted by  diminishing  the  ingestion  of  sugars,  starches,  and 
alcoholic  drinks.  Exercise  and  an  out-of-door  life  are  of  much 
service.  Any  disturbances  of  the  functions  of  the  stomach,  the 
liver,  or  the  bowels  should  be  remedied  as  far  as  possible.  The 
occasional  use  of  the  mineral  waters  and  baths  is  often  of  much 
service. 

Chronic  Gout. — The  patients  suffer  from  acute  attacks  at  vary- 
ing intervals,  but  between  the  attacks  their  health  is  not  good. 
The  joints  are  constantly  somewhat  inflamed,  and  become  stiff 
and  useless.  Urate  of  soda  is  deposited  in  masses  around  the 
joints  and  in  other  parts  of  the  body.  Disturbances  of  digestion 
are  troublesome  and  hard  to  relieve.  The  chronic  nephritis,  with 
its  attendant  symptoms,  advances  from  year  to  year.  The  com- 
plicating bronchitis,  emphysema,  endocarditis,  endarteritis,  ec- 
zema, or  diabetes  add  their  symptoms.  The  patients  grow  slowly 
worse  and,  if  not  cut  off  by  some  intercurrent  disease,  finally  die 
with  the  nephritis. 

Treatment. — The  indications  for  diet  and  treatment  are  the 
same  as  in  acute  gout.  The  natural  mineral  waters,  especially 
those  of  Carlsbad,  are  of  even  greater  service.  The  drugs  most 
frequently  used  are  colchicum  in  small  doses,  the  iodide  of  potash, 
guaiac,  the  preparations  of  potash,  soda,  and  lithia. 

Irregular  Gout. 

A  person  is  said  to  have  irregular  gout  when  he  has  the  gouty 
diathesis  and  suffers  from  one  or  more  of  the  complications  of 
gout. 

There  are  many  morbid  conditions,  none  of  them  confined  to 
gouty  persons,  which  may  be  caused  in  this  way  by  the  gouty 
disposition  : 

In  the  stomach — gastric  dyspepsia  and  catarrhal  gastritis. 


GOUT.  389 

In  the  liver — functional  disturbances  with  nervous  symptoms. 

In  the  heart — palpitation  and  disturbances  of  sensation. 

In  the  lungs — bronchitis. 

In  the  eyes — iritis. 

In  the  skin — eczema. 

In  the  urine — an  excess  of  urates,  glycosuria,  and  diabetes. 

In  the  kidneys — chronic  diffuse  nephritis. 

In  the  arteries — chronic  endarteritis,  inflammation  and  rup- 
ture of  the  cerebral  arteries. 

In  the  joints  of  the  fingers  and  toes — a  gradual  thickening  of 
the  ends  of  the  bones  without  pain. 

The  treatfnent .consists  in  the  use  of  remedial  measures  ap- 
propriate to  each  one  of  these  morbid  conditions,  and  at  the 
same  time  the  general  management  of  the  gouty  disposition. 


THE    INFECTIOUS    DISEASES. 


It  is  now  generally  believed  that  a  large  number  of  diseases 
and  inflammations  are  caused  by  the  presence  and  growth  of 
micro-organisms.  The  organisms  which  produce  suppuration, 
erysipelas,  lobar  pneumonia,  gonorrhoea,  anthrax,  tuberculosis, 
tetanus,  diphtheria,  cholera,  and  typhoid  fever  have  been  iso- 
lated, cultivated,  inoculated,  and  studied  in  many  different  ways. 
In  many  other  diseases  the  existence  of  such  organisms  is  prob- 
able, but  has  not  yet  been  demonstrated. 

These  organisms  seem  to  do  harm  in  several  different  ways  : 

1.  The  organisms  may  act  as  local  irritants,  and  by  their 
presence  in  the  tissues  set  up  about  them  an  exudative,  pro- 
ductive, or  necrotic  inflammation.  The  tubercle  bacilli  can  in 
this  way  set  up  a  productive  inflammation  even  when  they  are 
dead. 

2.  The  organisms  when  introduced  into  the  tissues  do  noth- 
ing unless  those  tissues  are  by  some  other  cause  inflamed.  The 
organisms  then  grow  in  these  inflamed  tissues  and  modify  the 
character  of  the  inflammation. 

3.  The  organisms  introduced  into  one  part  of  the  body  and 
growing  there,  may  find  their  way  into  distant  parts  of  the  body 
and  set  up  fresh  foci  of  inflammation,  but  without  constitutional 
infection.     We  see  this  in  gonorrhoeal  rheumatism. 

4.  The  organisms  when  introduced  into  one  part  of  the  body 
rapidly  multiply  and  are  soon  found  in  large  numbers  in  the 
blood  and  tissues  throughout  the  body.  They  seem  to  cause 
constitutional  symptoms  partly  by  their  numbers,  partly  by  the 
chemical  products  evolved  by  their  growth.  Anthrax  is  one  of 
the  best  examples  of  this. 

5.  The  organisms  when  introduced  into  one  part  of  the  body 
grow  and  multiply  there.  They  remain  confined  to  this  locality 
and  are  not  found  in  the  blood  or  in  other  parts  of  the   body. 


EPIDEMIC    CEREBRO-SPINAL    MENINGITIS.  39I 

They  produce  at  the  locality  where  they  grow  poisonous  cheini 
cal  products  which  affect,  more  or  less  intensely,  the  entire  body, 
and  give  rise  to  correspondingly  severe  constitutional  symptoms. 
We  see  this  in  ordinary  suppuration,  in  lobar  pneumonia,  and  in 
diphtheria. 

6.  It  has  been  found,  in  the  case  of  some  of  these  micro-or- 
ganisms, that  the  poisonous  chemical  products  evolved  by  their 
growth  can  confer  upon  animals  an  immunity,  either  against  the 
growth  of  the  same  micro-organism  or  against  the  effects  of  its 
chemical  poison. 

It  is  in  this  way  that  it  is  hoped  that,  in  the  future,  we  will  be 
able  to  arrest  or  modify  the  course  of  infectious  diseases  in  the 
human  being. 

7.  These  micro-organisms  can  be  conveyed  into  the  human 
body  by  inoculation,  by  inhalation,  or  by  swallowing.  As  a 
rule,  each  micro-organism  has  its  preference,  and  habitually  in- 
fects the  body  in  one  of  these  ways  rather  than  in  another. 
The  cocci  which  produce  abscesses,  or  erysipelas,  or  tetanus  are 
usually  inoculated  ;  the  bacilli  which  produce  pneumonia  are 
usually  inhaled  ;  those  which  cause  typhoid  fever  or  cholera  are 
swallowed. 

8.  In  m.any  of  the  infectious  diseases  there  is  always  present 
an  inflammation  of  the  skin,  of  the  mucous  membranes,  or  of 
the  viscera,  which  is  so  constant  that  we  call  it  the  characteristic 
lesion  of  the  disease.  The  micro-organisms  are  regularly  found 
most  constantly,  and  in  the  largest  numbers,  in  these  character- 
istic local  lesions. 

9.  It  is  found  that  while  some  persons  are  susceptible  to  the 
poisons  of  the  infectious  diseases,  other  persons  enjoy  an  immu- 
nity from  the  action  of  these  poisons.  It  is  also  found  that  in 
some  of  these  diseases  one  attack  protects  against  subsequent 
attacks  of  the  same  disease.  Temporary  conditions  of  atmos- 
phere, water,  soil,  and  uncleanliness  favor  the  development  of 
these  diseases.  Some  of  the  infectious  diseases  occur  only  from 
time  to  time  in  the  form  of  epidemics. 

Epidemic  Cerebro-spinal  Meningitis. 

Definition. — An  infectious  disease  of  which  the  characteristic 
lesion  is  an  acute  inflammation  of  the  pia  mater  of  the  brain  and 
of  the  spinal  cord. 


392  EPIDEMIC    CEREBRO-SPINAL    MENINGITIS. 

Synonyms. — Spotted  fever;  malignant  purpura;  typhus  pete- 
chialis  ;  typhoid  meningitis. 

History. — The  first  unquestionable  descriptions  of  the  dis- 
ease are  those  given  by  Vieusseux  and  Mathey  of  an  epidemic 
which  occurred  in  Geneva  in  1805.  Its  distinctive  features  were 
an  abrupt  attack  during  the  night,  vomiting,  severe  headache, 
rigidity  of  the  spine,  difficult  deglutition,  convulsions,  petechias, 
death  in  from  twelve  hours  to  five  days.  After  death  a  gelati- . 
nous  or  puriform  exudation  was  found  on  the  surface  of  the  brain 
and  of  the  medulla  oblongata.  Between  the  years  1806  and 
1816  there  were  localized  epidemics  in  Germany,  Holland, 
France,  England,  and  the  United  States.  Then  there  was  an 
interval  of  six  years  during  which  the  disease  disappeared.  In 
1822-23  there  were  small  epidemics  in  France  and  in  Connecti- 
cut. Then,  after  another  interval  of  five  years,  it  reappeared  in 
1828  in  Ohio,  two  years  later  in  England,  and  three  years  later 
in  Naples. 

After  four  years  of  quiescence  the  disease  entered  upon  a  wider 
career,  which  was  almost  uninterrupted  from  1837  to  1850,  and 
extended  over  a  large  part  of  Europe  and  of  the  United  States. 

Between  1850  and  1854  the  disease  again  disappeared.  Then 
there  was  a  very  fatal  epidemic  in  Sweden,  which  lasted  until 
1861.  In  1856-57  there  were  epidemics  at  different  places  in  the 
United  States.  From  i860  to  1865  the  disease  was  seen  in  Hol- 
land, Portugal,  and  Germany^.  From  1861  to  1872  there  were 
epidemics  in  many  parts  of  the  United  States,  the  disease  pre- 
vailing in  New  York  in  1872-73. 

Etiology. — It  is  evident,  from  the  history  of  the  disease,  that 
it  is  characteristic  of  it  to  appear  and  disappear  during  periods 
of  years  at  places  widely  separated  from  each  other.  Its  great- 
est prevalence  and  mortality  have  been  in  the  northern  portions 
of  the  temperate  zone  in  Europe  and  America,  and  during  the 
cool  seasons  of  the  year. 

No  locality  seems  to  be  exempt  from  the  disease.  It  is  seen 
in  cities,  villages,  isolated  houses  in  the  country,  barracks, 
prisons,  and  work-houses,  without  reference  to  soil  or  elevation. 
While  all  ages  are  liable  to  the  disease,  the  greatest  liability  is 
among  children  and  young  adults. 

It  is  generally  believed  that  the  poison  of  the  disease  is  not 
transmitted  from  person  to  person,  but  is  communicated  to  a 
number  of  persons  at  the  same  time. 


EPIDEMIC    CEREBRO-SPINAL   MENINGITIS.  393 

The  micro-organisms  which  seem  to  belong  most  constantly 
to  the  disease,  being  found  regularly  in  the  inflamed  pia  mater, 
are  the  pneumococci  of  Friinkel,  the  same  organisms  which  are 
found  in  pneumonia,  pleurisy,  pericarditis,  otitis,  peritonitis,  and 
in  the  saliva  and  nasal  secretions  of  healthy  persons.  It  is  very 
difficult  to  understand  how  a  disease  which  occurs  principally  in 
epidemics  separated  from  each  other  by  intervals  of  years,  should 
be  caused  by  one  of  the  most  common  of  the  bacteria. 

Lesions. — The  characteristic  lesion  of  the  disease  is  an  acute 
inflammation  of  the  pia  mater  of  the  brain  and  spinal  cord.  In 
the  great  majority  of  cases  this  is  a  simple  exudative  inflamma- 
tion, with  an  infiltration  of  the  pia  mater  with  serum,  fibrin,  and 
pus,  these  products  accumulating  in  the  largest  quantity  at  the 
base  of  the  brain  and  on  the  posterior  surface  of  the  cord.  The 
lateral  ventricles  contain  a  little  purulent  serum.  In  children  the 
quantity  of  purulent  serum  in  the  lateral  ventricles  is  often  so 
large  as  to  distend  them. 

In  a  few  cases  there  is  no  fibrin,  serum,  or  pus,  nothing  but 
an  increase  of  cells  in  the  pia  mater. 

In  a  few  cases  it  is  said  that  the  pia  mater  is  congested,  while 
no  exudate  is  present. 

Symptoms. — The  different  epidemics  of  the  disease  have  varied 
as  to  whether  the  invasion  was  sudden,  or  preceded  by  a  prodro- 
mic  period. 

If  the  prodromic  period  exists,  it  is  characterized  by  general 
malaise,  headache,  pains  in  the  bones,  loss  of  appetite,  conjunc- 
tivitis, chilliness,  and  a  slight  rise  of  temperature. 

When  the  invasion  is  sudden,  it  is  marked  by  one  or  more  of 
the  following  symptoms  :  Chills,  a  rise  in  temperature,  headache, 
vomiting,  tenderness  and  contraction  of  the  muscles  of  the  back 
of  the  neck,  irregular  pains  in  different  parts  of  the  body, 
conjunctivitis,  restlessness,  sleeplessness  or  delirium,  and  pros- 
tration. 

After  the  disease  is  fairly  established  the  following  are  the 
regular  symptoms  :  Pain  in  the  head — usually  frontal,  sometimes 
occipital  or  general — is  regularly  severe  and  constant  throughout 
the  disease.  The  suffering  is  very  great,  so  that  the  patients  com- 
plain of  it  most  bitterly,  and  even  after  they  have  become  par- 
tially unconscious,  from  time  to  time  they  cry  out  with  the  pain. 
Exceptionally  the  pain  is  but  moderate  and  intermits  from  time 
to  time. 


394  EPIDEMIC    CEREBRO-SPINAL   MENINGITIS. 

Pain,  tenderness,  and  contraction  of  the  muscles  of  the  back 
of  the  neck,  or  also  of  the  muscles  along  the  vertebral  column, 
are  often  present.  The  head  alone  is  drawn  back,  or  the  entire 
body  is  bent  back  and  rigid.  Any  attempt  to  move  the  con- 
tracted muscles  gives  intense  pain. 

There  may  be  severe  pain  along  the  course  of  the  spinal 
nerves,  pain  which  moves  rapidly  from  one  part  of  the  body  to 
another.  With  this  pain  there  may  also  be  hyperaesthesia  of  the 
skin.  Later  in  the  disease  the  pain  and  hyperaesthesia  are  suc- 
ceeded by  numbness  and  insensibility. 

There  may  be  contractions  of  groups  of  muscles,  especially 
of  the  muscles  of  the  face,  or  general  convulsions  ;  the  latter  is 
especially  common  in  children. 

Instead  of  involuntary  contractions  of  the  muscles,  there  may 
be  paralyses  either  of  the  muscles  of  deglutition,  or  of  those  of 
one  of  the  extremities,  or  of  those  of  a  large  part  of  the  body. 
Ptosis,  strabismus,  and  paralysis  of  the  bladder  and  rectum  occur 
quite  frequently. 

The  eyes  are  liable  to  a  variety  of  inflammations — conjunc- 
tivitis, keratitis,  or  choroiditis.  Independently  of  inflammation, 
there  is  at  first  photophobia  with  contracted  pupils,  later  insensi- 
bility to  light  with  dilated  pupils. 

The  hearing  is  at  first  unnaturally  acute  and  painful,  later  it 
is  dulled  or  lost.  In  some  epidemics  a  large  number  of  patients 
suffer  from  inflammations  of  the  ear,  which  leave  behind  perma- 
nent deafness. 

Restlessness,  sleeplessness,  delirium,  stupor,  and  coma  are 
present  in  various  degrees,  either  early  or  late  in  the  disease,  or 
throughout  its  entire  course.  The  delirium  is  mild,  or  active,  or 
so  violent  as  to  resemble  acute  mania.  The  establishment  of 
well-marked  delirium  and  stupor  alternating  with  each  other,  one 
or  the  other  predominating  as  the  disease  goes  on,  belongs  to  the 
severe  cases. 

Vomiting  is  a  very  common  symptom  at  the  beginning  of  the 
disease.  It  may  be  so  frequent  and  distressing  as  to  constitute  for 
a  time  the  most  important  symptom. 

The  bowels  are  usually  constipated,  but  during  the  later 
stages  of  the  disease  there  may  be  diarrhoea  and  involuntary 
evacuations. 

The  tongue  is  at  first  moist  and  coated,  later  dry  and  cracked, 
if  the  disease  is  of  severe  type. 


EPIDEMIC    CEREBRO-SPINAL   MENINGITIS.  395 

In  some  epidemics  it  is  reported  that  the  joints  were  inflamed. 
Sometimes  they  are  swollen,  red,  and  tender  ;  or  red  and  painful 
without  any  swelling  ;  or  swollen  and  painful  without  redness. 
The  joints  usually  attacked  are  the  knee,  elbow,  wrist,  and  the 
small  joints  of  the  fingers  and  toes. 

The  characteristic  pulse  of  the  disease  is  one  which  is  slow  in 
proportion  to  the  height  of  the  temperatures.  Pulses  of  60  and 
70  to  the  minute  are  quite  common,  and  ones  even  as  slow  as  27 
are  recorded.  But  exceptions  to  this  rule  are  not  infrequent,  and 
in  the  severe  cases  the  pulse  regularly  becomes  more  rapid  as  the 
disease  goes  on. 

In  the  accounts  of  the  earlier  epidemics  of  the  disease,  when 
no  thermometer  was  used,  it  is  frequently  stated  that  there  was 
no  fever.  Since  the  introduction  of  the  thermometer  it  has  been 
found  that  there  is  a  rise  of  temperature,  often  as  high  as  104°  F. 
But  the  curve  of  temperature  is  very  irregular  and  not  in  corre- 
spondence with  the  progress  of  the  disease.  A  patient  may  be 
doing  quite  as  badly  with  a  temperature  of  99°  F.  as  with  one  of 
104°  F. 

Eruptions  of  the  skin  are  present  in  some  epidemics,  absent 
in  others.  They  have  been  observed  more  frequently  in  the  epi- 
demics in  America  than  in  those  in  Europe.  When  the  disease 
first  appeared  in  New  England  a  large  proportion  of  the  cases 
exhibited  petechial  eruptions  and  ecchymotic  spots,  whence  the 
disease  received  the  name  of  spotted  fever.  There  have  been  ob- 
served in  different  epidemics  ecchymoses  in  the  skin,  petechise, 
erythema,  roseola,  urticaria,  and  pemphigus. 

The  severity  and  mortality  of  the  disease  has  varied  in  the 
different  epidemics.  In  some  the  disease  has  been  of  most  ma- 
lignant type,  the  mortality  as  high  as  seventy-five  per  cent.,  and 
many  of  the  cases  dying  within  a  few  hours.  In  others  the  mor- 
tality has  not  been  over  twenty  per  cent.,  and  the  duration  of  the 
disease  has  been  from  one  to  four  weeks. 

In  children  the  invasion  of  the  disease  is  often  marked  by  con- 
vulsions, which  may  afterward  be  frequently  repeated.  The  tem- 
perature is  high  and  the  pulse  rapid  throughout  the  disease. 
During  most  of  the  time  the  children  are  in  a  condition  of  stupor 
alternating  with  restlessness. 

In  the  regular  cases  there  may  be  a  temporary  cessation  of 
the  symptoms  for  several  hours,  or  even  for  two  or  three  days, 
and  then  they  go  on  as  before. 


396  EPIDEMIC    CEREBRO-SPINAL   MENINGITIS. 

The  disease  may  be  complicated  by  bronchitis,  pneumonia, 
pleurisy,  pericarditis,  or  endocarditis. 

During  the  past  few  years  I  have  seen  in  New  York  cases  of 
cerebro-spinal  meningitis  which  have  run  an  atypical  course. 

The  symptoms  have  come  on  gradually,  some  of  the  patients 
not  in  bed  until  after  several  days,  none  of  them  looking  very  sick 
for  the  first  one  or  two  weeks. 

In  some  of  the  patients  the  first  symptom  has  been  a  headache 
like  that  of  malaria  or  of  syphilis. 

In  others,  besides  the  headache,  there  have  also  been  loss  of 
appetite,  vomiting,  photophobia,  drowsiness,  sleeplessness,  ten- 
derness over  the  back  of  the  neck,  or  an  eruption  like  that  of  ty- 
phoid. 

In  still  others  there  has  been  no  headache,  only  prostration, 
sleeplessness,  and  a  little  fever. 

For  one  or  two  weeks,  or  even  longer,  the  patients  do  not 
look  very  sick.  They  make  you  think  of  malaria,  or  syphilis,  or  a 
mild  typhoid.  But  they  do  not  get  any  better,  they  lose  flesh  and 
strength,  develop  alternating  stupor  and  delirium,  and  finally  die 
after  from  four  to  eight  weeks. 

The  temperature  is  seldom  over  102°  F.,  often  down  to  99°  or 
even  97°  F. 

The  pulse  is  between  70  and  120.  After  death,  in  most  of 
the  patients  the  lesions  found  have  been  those  of  cellular  men- 
ingitis, but  in  one  case  there  was  a  large  exudation  of  fibrin  and 
pus  at  the  base  of  the  brain. 

Sequelce. — After  the  subsidence  of  the  meningitis  the  inflam- 
mation of  the  lateral  ventricles  may  continue.  The  patients 
begin  to  improve,  but  soon  fall  back.  There  is  progressive 
emaciation,  an  irregular  febrile  movement,  alternating  stupor 
and  delirium,  and  after  several  weeks  the  patients  die. 

Other  sequelae  are  :  blindness,  deafness,  mental  feebleness, 
aphasia,  anaemia,  hysterical  symptoms,  disordered  menstruation, 
paralyses  of  groups  of  muscles,  and  chronic  endocarditis. 

The  prognosis  of  the  disease  varies  in  different  epidemics, 
regularly  worse  during  the  commencement  and  height  of  each 
epidemic. 

Treatment. — There  are  two  main  indications  for  treatment — 
the  meningitis  and  the  general  condition  of  the  patient. 

For  the  meningitis  we  abstract  blood  from  the  temples  and 
the  nape  of  the  neck,  apply  continuous  cold  to  the  head,  and  ad- 


DIPHTHERIA.  397 


m 


inister  repeated  small  doses  of  calomel  or  the  sulphate  of 
magnesia.  The  iodide  of  potash  and  ergot  are  also  used  for  the 
same  purpose.  These  measures  are  most  likely  to  be  efficacious 
during  the  early  days  of  the  meningitis. 

For  the  headache,  restlessness,  sleeplessness,  and  delirium  we 
give  the  bromides,  chloral  hydrate,  or  opium. 

The  temperature  is  seldom  so  high  as  to  need  any  attention. 

The  heart's  action  may  be  so  feeble  as  to  require  the  use  of 
alcoholic  stimulants,  digitalis,  or  strophanthus. 

Excessive  vomiting  can  be  relieved  by  feeding  the  patients 
with  small  quantities  of  milk  to  which  oxalate  of  cerium,  bicar- 
bonate of  soda,  or  sulphonal  has  been  added. 

The  bowels  should  be  kept  open. 

Diphtheria. 

The  name  diphtheria,  first  employed  by  Bretonneau  in  1820, 
has  been  used  since  that  time  to  designate  the  inflammations 
accompanied  by  the  formation  of  a  false  membrane,  especially 
when  such  an  inflammation  occurs  in  the  throat,  nose,  or  larynx. 
For  many  years  the  true  character  of  the  disease  was  not  under- 
stood, but  more  recently  bacteriology  has  shown  us  that  of  these 
inflammations,  with  the  formation  of  a  false  membrane,  there  are 
several  distinct  forms.  We,  therefore,  now  describe  separately 
true  diphtheria  and  false  diphtheria. 

STREPTOCOCCUS    DIPHTHERIA. 

Etiology. — Streptococci  are  micro-organisms  which  are  found 
in  rooms  and  dwellings,  especially  if  these  rooms  are  over- 
croAvded  and  unclean.  They  are  found  in  the  secretions  of  the 
nose,  mouth,  and  vagina  in  healthy  persons.  They  grow  and 
thrive  in  inflamed  tissues,  and  increase  the  severity  of  the  inflam- 
mation. They  can  be  transported  by  the  blood  and  lodged  as 
infectious  emboli  in  distant  parts  of  the  body.  They  vary  greatly 
as  to  the  intensity  of  the  chemical  poison  produced  by  their 
growth,  and  the  consequent  severity  of  the  constitutional  symp- 
toms. They  are  found  in  erysipelas,  suppurating  inflammations, 
pleurisy,  malignant  epdocarditis,  puerperal  septicaemia,  and  in 
.inflammations  caused  by  other  bacteria. 

Streptococcus  diphtheria   is  caused  by  the  inflammations  of 


398  DIPHTHERIA. 

the  nose,  throat,  and  larynx  which  accompany  measles  and 
scarlet  fever,  especially  if  these  diseases  occur  in  an  asylum 
where  the  rooms  are  full  of  streptococci.  It  also  occurs  in 
isolated  cases,  or  in  groups  of  persons  in  whom  the  throat  be- 
comes inflamed  from  any  cause.  It  is  much  more  common  in 
children  than  in  adults.  It  would  seem  probable  that  it  is  not 
communicated  from  person  to  person,  but  that  the  infection  comes 
from  the  streptococci  which  are  so  frequently  present  in  the  air. 

Lesions. — There  is  a  croupous  inflammation  of  the  mucous 
membrane  of  the  tonsils,  pharynx,  nose,  or  larynx.  The  in- 
flamed mucous  membrane  is  congested,  swollen,  infiltrated  with 
fibrin,  pus,  and  coated  with  a  false  membrane  composed  of  fibrin, 
pus,  and  dead  epithelium.  The  streptococci  are  found  in  the 
false  membrane  and  the  mucous  membrane  beneath  it.  The  in- 
flammation often  travels  down  the  bronchi  and  produces  a 
broncho-pneumonia.  There  does  not  seem  to  be  the  same  dis- 
position to  acute  degeneration  of  the  viscera  and  of  the  nerves 
that  exists  in  the  Klebs-Loffler  diphtheria. 

Symptoms. — The  symptoms  are  especially  those  belonging  to 
the  local  inflammation.  The  obstruction  in  the  nose,  the  pain 
in  the  throat,  the  cough  and  dyspnoea  of  the  laryngitis  are  regu- 
larly present.  The  principal  constitutional  symptoms  are  the 
rise  of  temperature  and  the  disturbance?  that  go  with  it.  Other- 
wise there  is  little  evidence  of  general  poisoning.  The  principal 
dangers  are  from  the  laryngitis  and  the  broncho-pneumonia.  If 
the  patient  escapes  these  the  probabilities  of  recovery  are  good. 
The  disease  runs  its  course,  exclusive  of  the  broncho-pneumonia, 
within  a  week  or  two  weeks.  When  only  the  tonsils  or  pharynx 
are  involved  the  patients,  as  a  rule,  are  not  at  any  time  very  sick. 

There  are,  however,  cases  of  streptococcus  diphtheria  which 
are  much  more  serious.  There  is  necrosis  of  the  tissues  adjacent 
to  the  inflamed  mucous  membrane.  The  patients  give  all  the 
evidences  of  septic  poisoning  and  are  very  apt  to  die.  These 
bad  cases  are  especially  frequent  as  complications  of  scarlatina. 

Treatment. — It  is  not  considered  necessary  to  isolate  patients 
who  have  streptococcus  diphtheria.  But  the  occurrence  of  any 
number  of  such  cases  in  one  building  means  that  the  building 
needs  a  thorough  cleaning. 

The  treatment  of  the  inflammation  is  local.  It  consists  in  the 
frequent  irrigation  of  the  inflamed  mucous  membrane  with  solu- 
tions of  bichloride  of  mercury  or  peroxide  of  hydrogen. 


DIPHTHERIA.  399 


TRUE    DIPHTHERIA. 


Etiology. — The  Klebs-Loffler  bacillus  is  about  the  length  of 
the  tubercle  bacillus.  It  does  not  multiply,  or  does  so  very  slug- 
gishly, at  a  point  below  64°  F.  It  is  killed  by  exposure  for  ten 
minutes  to  a  temperature  of  136°  F.  It  remains  alive  outside  of 
the  body,  in  spite  of  drying  and  unfavorable  influences,  for  many 
months.  It  develops  only  locally  at  the  seat  of  infection,  and 
does  not  invade  the  tissues  or  the  circulation.  It  is  found  in  the 
false  membrane,  and  not  in  the  mucous  membrane  beneath  it. 

The  bacilli  are  conveyed  from  one  person  to  another  in  the 
portions  of  false  membrane  and  saliva  discharged  from  the  mouth 
and  nose.  These  infectious  particles  may  become  lodged  about 
the  person  and  clothing  of  the  patient,  and  in  the  bedding,  fur- 
niture, etc.  The  bacilli  are  probably  not  present  in  the  breath  of 
the  patient.  As  they  are  not  destroyed  by  drying,  after  they  have 
been  lodged  in  the  clothing,  etc.,  they  can  float  in  the  air  and  be 
inhaled. 

The  bacilli,  either  when  growing  in  the  false  membrane,  or 
when  cultivated  outside  the  body,  produce  a  toxic  substance  of 
the  most  virulent  character.  This  substance,  when  inoculated  in 
animals,  produces  all  of  the  changes  in  the  body  which  follow 
the  inoculation  of  pure  cultures  of  the  bacilli,  with  the  exception 
of  the  false  membrane. 

True  diphtheria,  therefore,  is  a  disease  communicated  from 
person  to  person  by  a  specific  bacillus  which  grows  in  the  false 
membrane.  The  inoculation  is  ordinarily  effected  in  the  mucous 
membrane  of  the  throat,  nose,  or  larynx.  It  is  probable  that  an 
antecedent  inflammation  of  these  mucous  membranes  favors  the 
inoculation.  Children  are  more  susceptible  than  are  adults.  The 
disease  prevails  more  extensively  during  some  years  than  during 
others. 

The  disease  begins  as  a  local  inflammation,  and  the  constitu- 
tional symptoms  and  secondary  lesions  are  due  to  a  poison  which 
is  formed  by  the  growth  of  the  bacteria. 

The  Loffler  bacilli  usually  disappear  from  the  throat  within 
three  days  after  the  complete  disappearance  of  the  exudation, 
but  it  is  not  rare  to  find  them  for  as  long  as  seven  days,  and  cases 
are  recorded  in  which  the  bacilli  were  found  for  nine  weeks  after 
the  disappearance  of  all  membrane. 


400  DIPHTHERIA. 

It  is  well  established  that  virulent  and  non-virulent  diphtheria 
bacilli  are  found  in  the  throats  of  healthy  persons,  and  that  this  is 
more  apt  to  occur  if  they  have  been  exposed  to  diphtheria.  The 
same  thing  is  true  of  diphtheria  bacilli  as  of  streptococci  and 
pneumococci,  that,  although  they  are  capable  of  producing  viru- 
lent poisons,  they  can  also  grow  in  the  human  body  without  do- 
ing any  harm. 

It  is  to  be  remembered  that  in  diphtheria  the  infection  is  not 
with  diphtheria  bacilli  alone,  but  that  it  is  a  mixed  infection,  as 
either  streptococci,  or  staphylococci,  or  both,  are  also  usually 
present. 

Lesions. — The  mucous  membranes  ordinarily  inflamed  are 
those  of  the  tonsils,  pharynx,  nose,  larynx,  trachea,  and  bronchi. 
The  inflammation  begins  in  one  of  these  situations,  and  then  is 
apt  to  extend  to  the  others.  The  inflamed  mucous  membrane  is 
congested,  swollen,  infiltrated  with  serum,  fibrin,  and  pus  ;  its 
surface  is  coated  with  a  false  membrane  composed  of  fibrin,  pus, 
and  necrotic  epithelium.  The  necrosis  involves  the  epithelium 
alone,  or  also  portions  of  the  stroma  of  the  inflamed  mucous 
membrane.  In  the  false  membrane  are  found  the  Klebs-Loffler 
bacilli,  and  in  addition  a  variety  of  other  micro-organisms.  The 
cases  vary  much  as  to  the  intensity  of  the  inflammation  and  the 
quantity  of  false  membrane. 

Beside  the  regular  cases  of  croupous  inflammation  caused  by 
the  diphtheria  bacillus,  there  are  examples  of  ordinary  catarrhal 
inflammation  of  the  mucous  membrane  of  the  pharynx  and  ton- 
sils also  accompanied  by  the  growth  of  the  diphtheria  bacillus. 
It  is  customary  to  include  these  cases  under  the  name  of  diph- 
theria. 

The  inflammation  may  extend  down  the  trachea  and  produce 
a  broncho-pneumonia. 

The  adjacent  lymphatic  glands  are  often  inflamed  and  swol- 
len, with  more  or  less  necrosis  of  their  cells. 

The  kidneys  become  the  seat  of  acute  degeneration,  acute 
exudative  nephritis,  or  acute  diffuse  nephritis. 

The  nerves  may  become  the  seat  of  acute  degeneration. 

The  sympt07ns  of  diphtheria  are  both  local  and  constitutional. 

The  appearance  of  the  inflamed  throat  varies  with  the  exact 
character  of  the  inflammation.  The  mucous  membrane  is  swollen, 
congested,  red,  coated  here  and  there  with  small  patches  of  false 
membrane,  or  covered  with  a  very  thin  membrane,  or  very  much 


DIPHTHERIA.  4OI 

swollen  and  covered  everywhere  with  a  thick  membrane.  The 
inflammation  remains  confined  to  the  situation  where  it  began, 
or  it  extends.  It  regularly  runs  its  course  by  the  end  of  seven 
days,  then  the  swelling  diminishes,  the  mucous  glands  pour  out 
an  increased  quantity  of  mucus,  and  the  false  membranes  become 
detached. 

When  the  quantity  of  false  membrane  is  great  it  undergoes 
putrefaction,  and  the  patient's  breath  has  a  foul  smell. 

The  sore  throat  is  regularly,  but  not  always,  accompanied  by 
pain  and  difficulty  in  swallowing. 

With  the  inflammation  of  the  tonsils  and  pharynx  there  is 
often  more  or  less  swelling  of  the  lymphatic  and  salivary  glands 
in  the  neck. 

If  the  inflammation  begins  in  the  nose,  it  gives  at  first  few 
symptoms  and  is  easily  overlooked. 

The  inflammation  may  begin  in  the  larynx,  or  it  may  extend 
to  it  after  from  five  to  seven  days.  It  is  attended  with  laryngeal 
cough,  voice,  and  dyspnoea.  Such  a  laryngitis  is  always  danger- 
ous, especially  in  children. 

Broncho-pneumonia,  either  with  or  without  laryngitis,  may 
be  developed  from  the  fifth  to  the  seventh  day  of  the  disease. 
The  physical  signs  are  the  ordinary  ones  of  broncho-pneumonia. 
With  this  complication  all  of  the  patients  at  once  look  decidedly 
worse,  but  only  in  some  of  them  are  there  pulmonary  symptoms. 
This  lesion  is  a  very  fatal  one. 

The  invasion  of  the  disease  is  marked  in  some  cases  only  by 
the  sore  throat  or  the  laryngitis ;  in  other  cases  by  chills,  a 
rapid  rise  of  temperature,  or  general  convulsions. 

A  febrile  movement  may  be  absent  throughout  the  disease  ; 
may  be  one  of  the  first  symptoms  and  continue  nearly  up  to  the 
time  of  the  patient's  death  ;  may  be  present  at  first  and  then  sub- 
side, although  the  other  symptoms  continue  ;  may  be  absent  at 
first  and  not  appear  until  several  days  after  the  development  of 
the  throat  lesion.  In  some  of  the  worst  cases  there  is  little  or 
no  fever. 

Vomiting  may  be  a  troublesome  symptom  at  any  time  in  the 
disease. 

Diarrhoea  is  occasionally  present. 

The  heart's  action  and  the  radial  pulse  become  rapid  and 
feeble  according  to  the  severity  of  the  disease. 

The  patients  are  liable  during  the  disease,  and  during  conva- 


402  DIPHTHERIA. 

lescence,  even  as  late  as  three  or  four  weeks  after  the  invasion  of 
the  disease,  to  attacks  of  heart  failure.  These  attacks  of  heart 
failure  occur  in  one  of  two  ways  :  The  patient  may  be  in  his  or- 
dinary condition,  when  the  heart  w^ill  suddenly  stop  and  death  is 
almost  instantaneous.  Or  the  heart's  action  becomes  very  rapid 
and  feeble,  with  cardiac  dyspnoea  and  venous  congestion  ;  it  con- 
tinues to  get  worse  for  a  number  of  hours  until  the  patient  dies. 

In  most  of  the  patients  the  kidneys  are  diseased  in  one  of 
three  ways. 

There  may  be  acute  degeneration  of  the  kidney.  The  urine 
is  diminished,  its  specific  gravity  remains  normal,  it  contains 
little  or  no  albumin.  This  change  in  the  kidneys  seems  to  add 
little  to  the  dangers  of  tlie  diphtheria. 

There  may  be  acute  exudative  nephritis.  The  urine  is  dimin- 
ished in  quantity,  its  specific  gravity  remains  normal,  it  contains 
much  albumin  and  many  casts.  Such  a  complicating  nephritis 
may  prove  fatal. 

There  may  be  acute  diffuse  nephritis.  This  occurs  during 
convalescence.  The  symptoms  are  acute  or  subacute.  The 
nephritis  regularly  persists  and  becomes  chronic. 

Course  of  the  Disease. — i.  The  Malignant  Cases,  (a)  The  inva- 
sion of  the  disease  is  acute.  It  may  begin  with  general  convul- 
sions. The  temperature  rises  rapidly.  The  inflammation  of  the 
throat  is  severe,  extensive,  and  rapidly  extends,  with  great  swell- 
ing and  a  large  production  of  false  membrane.  The  salivary  and 
lymphatic  glands  in  the  neck  are  usually  swollen.  The  patients 
rapidly  become  worse,  stupor  and  delirium  are  developed,  and 
death  follows  in  from  three  to  five  days. 

{b)  The  invasion  of  the  disease  is  slow  and  gradual.  The 
child  is  at  first  ailing,  but  without  fever  or  pain  in  the  throat. 
The  neck  is  swollen,  the  throat  is  congested,  with  little  or  no  visi- 
ble false  membrane,  the  skin  is  pale  and  cool,  a  dirt-brown  fluid 
exudes  from  the  mouth  and  nose.  The  patient  dies  in  collapse 
in  from  three  days  to  two  weeks. 

2.  The  Ordinary  Cases.  One  tonsil  is  inflamed  with  a  small 
patch  of  membrane  on  it.  Fever  is  present  or  absent.  The  in- 
flammation and  the  false  membrane  gradually  spread  over  the 
rest  of  the  throat,  with  more  or  less  fever,  vomiting,  and  prostra- 
tion. By  the  seventh  day  the  inflammation  of  the  throat  sub- 
sides, the  membrane  begins  to  come  away,  and  there  is  an  in- 
creased production  of  mucus.     If  tlie  larynx  or  bronchi  are  not 


DIPHTHERIA.  403 

involved  the  patients  get  better  and  are  convalescent  by  the  end 
of  three  weeks.  The  complicating  laryngitis  and  broncho-pneu- 
monia are  liable  to  be  developed  between  the  fifth  and  tenth  day, 
with  their  characteristic  symptoms.  The  cases  vary  as  to  the 
predominance  of  the  throat  or  the  constitutional  symptoms,  and 
as  to  the  sthenic  or  asthenic  t3'pe  of  the  disease.  All  the  patients 
are  liable  to  attaci<s  of  heart  failure  and  to  sequelae. 

3.  Cases  in  which  both  the  throat  lesions  and  the  constitu- 
tional symptoms  are  but  slightly  developed.  These  patients  do 
very  well,  but  they  are  a  source  of  danger  to  the  community  ; 
for  they  are  not  confined  to  bed,  nor  to  the  hcnise,  and  so  are 
likely  to  transmit  the  disease  to  other  persons. 

4.  Cases  which  at  first  have  mild  local  and  constitutional 
symptoms.  But  after  a  few  days  the  inflammation  of  the  throat 
suddenly  becomes  worse  and  the  patients  much  prostrated. 
Such  patients  often  do  badly.  The  duration  of  the  disease  has 
to  be  dated  from  the  day  when  the  patients  suddenly  become 
worse. 

5.  Cases  in  which  the  larynx  is  first  inflamed.  This  is  es- 
pecially common  in  young  children.  The  first  symptoms  are 
those  of  the  laryngitis,  the  symptoms  of  the  diphtheria  are  de- 
veloped later.     This  is  a  very  fatal  form  of  the  disease 

6.  Cases  in  which  the  disease  is  protracted.  The  inflamma- 
tion of  the  throat  runs  its  course  within  seven  days,  and  the  false 
membrane  begins  to  come  away.  But  after  a  day  or  so  a  fresh 
attack  of  inflammation,  with  a  new  false  membrane,  are  devel- 
oped, and  this  may  be  repeated  several  times  ;  although  these 
patients  are  sick  for  a  long  time,  most  of  them  eventually  re- 
cover. 

7.  Cases  which  behave  like  ordinary  cases  of  catarrhal  phar- 
yngitis or  tonsillitis,  but  yet  there  are  virulent  bacilli  on  the  sur- 
face of  the  mucous  membrane  or  in  the  crypts  of  the  tonsils. 
The  diagnosis  has  to  be  made  by  the  bacteriological  examination. 

The  convalescence  after  diphtheria  is  slow,  and  it  is  often 
months  before  the  patients  fairly  regain  their  health. 

Sequelce  are  of  frequent  occurrence.  There  may  be  paralyses 
of  groups  of  muscles,  apparently  due  to  inflammation  or  degen- 
eration of  the  peripheral  nerves.  The  muscles  usually  paralyzed 
are  those  of  the  soft  palate,  the  pharynx,  the  larynx,  and  the  eye, 
the  muscles  which  control  respiration,  and  the  muscles  of  the 
arms  and  legs.     These  paralyses,  as  a  rule,  after  lasting  for  weeks 


404  DIPHTHERIA. 

or  months,  disappear.  They  are  not  dangerous  to  life  unless 
they  involve  the  muscles  of  respiration. 

A  post  diphtheritic  subacute  productive  nephritis  may  be  de- 
veloped. 

There  may  be  sudden  or  prolonged  heart  failure. 

The  prognosis  of  the  streptococcus  diphtheria  is  very  much 
better  than  that  of  true  diphtheria.  But  yet,  if  the  larynx  is  in- 
volved, if  there  is  broncho-pneumonia,  or  if  the  patients  are  ver}-- 
young,  the  danger  is  great. 

In  true  diphtheria  the  prognosis  varies  with  the  intensity  of 
the  poison  produced  by  the  bacilli,  with  the  presence  or  absence 
of  laryngitis  and  broncho-pneumonia,  and  with  the  age  of  the 
patient. 

Prophylaxis. — The  prevention  of  streptococcus  diphtheria  is 
of  especial  importance  in  children's  hospitals  and  asylums.  By 
sufficient  care  in  keeping  the  rooms  and  wards  clean,  the  ordi- 
nary cases  of  measles,  scarlet  fever,  and  whooping-cough  will 
run  their  course  without  any  complicating  diphtheria.  In  the 
case  of  persons  suffering  from  the  disease  the  discharges  from  the 
mouth  and  nose  should  all  be  received  into  germicide  solutions 
of  sufficient  strength  to  destroy  the  streptococci. 

In  true  diphtheria  the  danger  lies  in  the  false  membrane. 
The  most  minute  care,  therefore,  is  necessary  that  all  the  dis- 
charges of  the  mouth  and  nose  should  be  received  into  germicide 
solutions.  Even  with  the  greatest  precautions,  fragments  of  the 
membrane  become  lodged  in  the  bedding,  clothing,  carpets,  etc. 
All  the  clothing,  therefore,  should  be  steamed  and  washed,  the 
mattresses  and  pillows  destro3^ed,  the  carpets  taken  up  and 
cleansed,  the  furniture  and  room  washed  with  bichloride  solution 
and  repainted. 

Treatment. — The  first  thing  is  to  determine  whether  the  pa- 
tient is  suffering  from  streptococcus  diphtheria  or  from  true 
diphtheria.  This  is  done  most  certainly  by  a  bacteriological  ex- 
amination. For  this  purpose  we  are,  in  New  York,  supplied  by 
the  Board  of  Health  with  a  culture  outfit  which  consists  of  a 
small  wooden  box  containing  a  tube  of  blood  serum  and  a  tube 
containing  a  swab. 

The  patient  should  be  placed  in  a  good  light,  and,  if  a  child, 
properly  held.  The  swab  is  removed  from  its  tube,  and  while 
the  tongue  is  depressed  with  a  spoon  it  is  passed  into  the  phar- 
ynx (if  possible,  without   touching  the   tongue),  and   is   rubbed 


DIPHTHERIA.  405 

gently  but  firmly  against  any  visible  membrane  on  the  tonsils  or 
in  the  pharynx,  and  then,  without  laying  the  swab  down,  it  is 
immediately  inserted  in  the  blood-serum  tube,  and  the  portion 
which  has  been  previously  in  contact  with  the  exudate  is  rubbed 
a  number  of  times  back  and  forth  over  the  whole  surface  of  the 
serum.  This  should  be  thoroughly  done,  but  it  is  to  be  gently 
done,  so  as  not  to  break  the  surface  of  the  serum.  The  swab  is 
replaced  in  its  tube,  and  both  tubes,  their  cotton  plugs  having 
been  inserted,  are  returned  to  the  box  and  sent  to  the  collecting 
station.  The  blank  forms  of  report  which  accompany  each  out- 
fit should  be  completely  filled  out  and  forwarded  to  the  station 
with  the  tubes. 

Where  there  is  no  visible  membrane  (it  may  be  present  in  the 
nose  or  pharynx)  the  swab  should  be  thoroughly  rubbed  over 
the  mucous  membrane  of  the  pharynx  and  tonsils,  and  in  nasal 
cases,  when  possible,  a  culture  should  also  be  made  from  the 
nose.  In  little  children,  care  should  be  taken  not  to  use  the 
swab  when  the  throat  contains  food  or  vomited  matter,  as  then 
the  bacterial  examination  is  rendered  more  difficult.  Under  no 
conditions  should  any  attempt  be  made  to  collect  the  material 
shortly  after  the  application  of  disinfectants  (especially  solutions 
of  corrosive  sublimate)  to  the  throat.  If  any  of  these  instructions 
have  not  been  carried  out,  the  fact  should  be  carefully  noted  on 
the  record  blank. 

The  culture-tubes  which  have  been  inoculated  as  described 
above,  are  kept  in  an  incubator  at  37°  C.  for  twelve  hours,  and 
are  then  ready  for  examination.  On  inspection,  it  will  be  seen 
the  surface  of  the  blood  serum  is  dotted  with  very  numerous  col- 
onies, which  are  just  visible.  At  this  time  no  diagnosis  can  be 
made  from  simple  inspection  (if,  however,  the  serum  is  found 
liquefied,  or  shows  other  evidences  of  contamination,  the  exam- 
ination will  probably  be  unsatisfactory).  A  microscopical  prepa- 
ration is  now  made  by  placing  a  tiny  drop  of  water  upon  a  clean 
cover-glass,  and  then  a  platinum  needle  is  inserted  in  the  tube, 
and  quite  a  large  number  of  colonies  are  swept  with  it  from  the 
surface  of  the  culture  medium.  The  bacteria  adherent  to  the 
needle  are  washed  off  in  the  drop  of  water  previously  placed  on 
the  cover-glass  and  smeared  over  its  surface.  The  bacteria  on 
the  glass  are  then  allowed  to  dry  in  the  air.  The  cover-glass  is 
then  passed  quickly  through  the  fiame  of  a  Bunsen  burner  or  al- 
cohol  lamp   three  times   in   the  usual   way,  covered  with  a  few 


406  DIPHTHERIA. 

drops  of  Loffler's  solution  of  alkaline  methyl  blue,  and  left  with- 
out heating  for  ten  niinutes.  It  is  then  rinsed  off  in  clean  water, 
dried,  and  mounted  in  balsam. 

In  the  great  majority  of  cases,  one  of  two  pictures  will  be 
seen  with  the  -^^  oil  immersion  lens  ;  either  an  enormous  number 
of  characteristic  Loffier  bacilli  with  a  moderate  number  of  cocci 
or  a  pure  culture  of  cocci,  mostly  in  pairs  or  short  chains.  In  a 
few  cases  there  will  be  an  approximately  even  mixture  of  Lof- 
fier bacilli  and  cocci,  and  in  others  a  great  excess  of  cocci.  Be- 
sides these  there  will  be  occasionally  met  preparations  in  which, 
with  the  cocci,  there  are  mingled  bacilli  more  or  less  resembling 
the  Loffler  bacilli.  These  bacilli,  which  are  pseudo-diphtheria 
bacilli,  are  especially  frequent  in  cultures  from  the  nose. 

In  not  more  than  one  case  in  twenty  will  there  be  any  serious 
difficulty  in  making  the  diagnosis,  if  the  serum-tube  has  been 
properly  inoculated.  In  such  a  case,  another  culture  must  be 
made. 

All  treatment  is  most  efficacious  during  the  first  three  days  of 
diphtheria.  The  local  treatment  of  the  throat  and  nose  is  best 
carried  out  by  frequent  irrigations  with  solutions  of  bichloride  of 
mercury  in  the  strength  of  from  i  to  4,000,  to  i  to  10,000,  or  of  a 
three  per  cent,  solution  of  peroxide  of  hydrogen. 

The  best  local  treatment  for  the  lar^'nx  seems  to  be  by  the  in- 
halation of  the  fumes  of  calomel.  But  if  the  larynx  is  much 
obstructed  either  intubation  or  tracheotomy  becomes  necessary 
to  prevent  suffocation. 

To  counteract  the  effects  of  the  poisoning  it  has  been  custom- 
ary to  use  alcoholic  stimulants  in  considerable  quantities,  and 
the  tincture  of  the  chloride  of  iron  in  doses  of  from  five  to 
twenty  minims  every  two  hours. 

Since  the  year  1893  the  treatment  of  diphtheria  by  antitoxin 
has  been  carried  on  in  many  different  places  and  with  large  num- 
bers of  patients.  It  is  the  belief  of  those  best  qualified  to  judge 
that  by  this  treatment  the  mortality  from  diphtheria  can  be  very 
much  diminished. 

The  so-called  diphtheria  antitoxin  is  prepared  in  the  follow- 
ing way  :  Pure  cultures  of  the  diphtheria  bacillus  are  allowed  to 
grow  in  bouillon.  As  they  grow  the  toxins  of  diphtheria  are 
formed  and  held  in  solution  in  the  bouillon.  If  the  bouillon  is 
filtered  we  have  a  fluid  containing  toxins.  To  determine  the 
strength   of  this  solution  we  employ  injections  into  guinea-pigs. 


DIPHTHERIA.  407 

When  the  strength  of  the  toxin  solution  is  such  that  o.i  c.c. 
kills  a  guinea-pig  of  about  250  grammes  weight  within  forty- 
eight  hours,  it  is  called  normal  or  standard  toxin.  This  is  the 
solution  of  toxins  which  is  used  to  immunize  animals.  The  ani- 
mal which  has  been  found  to  be  the  most  convenient  for  this 
purpose  is  the  horse.  In  order  to  immunize  a  horse  we  be- 
gin with  subcutaneous  injections  of  half  a  cubic  centimetre  of 
standard  toxin.  The  injections  are  repeated  at  intervals  with 
gradually  increased  quantities  of  toxin  until  the  animal  tolerates 
as  much  as  200  c.c.  at  one  injection.  The  time  required  to  ac- 
quire such  a  tolerance  is  about  three  months,  and  the  horse  is 
then  said  to  be  immunized. 

The  next  thing  is  to  obtain  the  blood  serum  of  the  immu- 
nized animal.  For  this  purpose,  from  6  to  8  litres  of  blood  are 
drawn  off  from  the  jugular  vein.  This  blood  is  allowed  to  clot 
in  a  cool  place,  the  serum  is  drawn  off,  a  little  carbolic  acid  or 
other  antiseptic  is  added,  and  we  have  the  antitoxin  serum.  Be- 
fore it  is  used  the  strength  of  each  batch  of  the  antitoxin  serum 
has  to  be  determined.  This  is  done  by  finding  out  how  large  a 
quantity  of  antitoxin  will  render  the  standard  toxin  harmless 
to  guinea-pigs.  If  o. i  c.c.  of  antitoxin  renders  i  c.c.  of  normal 
toxin  harmless  to  a  guinea-pig  weighing  250  grammes,  it  is 
called  normal  antitoxin,  and  i  c.c.  of  normal  antitoxin  is 
called  an  antitoxin  unit.  The  serum  employed  in  practice  is 
made  so  strong  that  i  c.c.  contains  the  strength  of  many  antitoxin 
units.  Experience  has  shown  that  to  use  antitoxin  for  the  cure 
of  diphtheria  it  must  be  employed  within  the  first  three  days  of 
the  disease.  The  quantity  injected  at  one  time  varies  between 
600  and  1,500  normal  antitoxin  units  in  about  10  c.c.  of  serum, 
according  to  the  age  of  the  patient  and  the  severity  of  the  dis- 
ease. 

In  the  favorable  cases  improvement  begins  within  twenty-four 
hours  after  the  injection.  The  local  inflammation  subsides  and 
the  membrane  begins  to  become  detached  ;  the  fever  and  other 
constitutional  symptoms  also  become  less  severe. 

How  far  the  sequelae  of  diphtheria-nephritis — heart  failure 
and  paralysis — are  favorably  affected  by  antitoxin  is  not  exactly 
determined. 

The  antitoxin  itself  may  produce  some  poisonous  effects.  In- 
flammations of  the  skin  like  those  of  erythema,  urticaria,  measles, 
and  scarlatina  are  of  not  infrequent  occurrence.     While  in  some 


408  EPIDEMIC    INFLUENZA. 

patients  fever,  prostration,  with  pain  and  swelling  of  the  joints, 
are  observed. 

Throughout  the  disease  attention  to  the  nursing  and  feeding 
is  of  the  greatest  importance. 

The  convalescence  is  often  tedious,  and  it  may  be  months  be- 
fore the  patient's  health  is  fully  restored. 

Epidemic  Influenza. 

Synonyms. — Epidemic  Catarrhal  Fever  ;  La  Grippe. 

Definition. — An  infectious  disease,  caused  by  the  presence  and 
growth  of  the  influenza  bacillus,  characterized  by  a  rise  of  tem- 
perature, prostration,  pains  and  inflammations  of  different  parts 
of  the  body.  The  parts  of  the  body  which  may  be  inflamed  are  : 
the  pia  mater,  the  peripheral  nerves,  the  mucous  membranes  of 
the  nose,  throat,  larynx,  bronchi,  stomach,  and  colon,  the  lungs, 
the  pleura,  the  pericardium,  and  the  skin. 

History  and  Causes  (Ziemssen). — Tlie  history  of  influenza  can 
be  traced  back  with  certainty  only  to  the  beginning  of  the  six- 
teenth century.  With  the  year  15 lo  begins  a  series  of  epidemics 
the  wide  distribution  of  which  has  been  reached  by  no  other 
acute  infectious  disease.  Up  to  the  year  1870,  more  than  ninety 
epidemics  have  been  described,  which  generally  extended  over 
whole  countries,  or  whole  quarters  of  the  earth.  As  a  rule,  the 
epidemics  advance  from  the  east  and  northeast  toward  the  west. 
Sometimes  they  occur  simultaneously  at  several  different  parts 
of  the  earth.  The  epidemics  lasted,  as  a  rule,  only  four  to  six 
weeks  ;  only  exceptionally,  as  in  Paris  in  183 1,  have  they  lasted 
for  nine  or  ten  months.  Wherever  the  epidemics  prevail,  very 
large  numbers  of  the  population  are  attacked.  There  is  no 
special  liability  or  immunity  by  reason  of  age,  sex,  constitution, 
or  condition  of  life  ;  but  in  some  epidemics  children  are  exempt. 
The  influenza,  as  such,  is  not  usually  fatal,  but  while  it  prevails 
the  general  death-rate  is  increased.  Climate  and  atmospheric 
influences  seem  to  exert  no  effect.  One  attack  of  the  disease 
does  not  protect  against  subsequent  attacks. 

Lesions. — The  bacillus  which  is  believed  to  be  characteristic  of 
influenza  has  been  found  in  the  sputum,  the  lungs,  and  the 
blood.     The  inflammations  which  it  causes  are  of  exudative  type. 

The  pia  mater  of  the  brain  and  cord  is  infiltrated  with  serum, 
fibrin,  and  pus. 


EPIDEMIC    INFLUENZA.  409 

The  sheaths  of  the  nerves  are  swollen.  The  changes  in  the 
mucous  membranes  of  the  frontal  sinuses,  nose,  throat,  and 
larynx  are  those  of  an  ordinary  acute  catarrhal  inflammation. 
The  bronchitis  is  characterized  by  an  unusually  large  production 
of  mucus,  and  of  pus-cells  with  considerable  disposition  to 
bleeding. 

In  the  lungs  the  pneumonia  is  of  the  lobar  form,  but  with  a 
tendency  to  excessive  congestion  and  incomplete  hepatization. 

The  pleurisy  and  the  pericarditis  may  be  with  fibrin  alone, 
or  with  fibrin  and  serum,  or  with  fibrin,  serum,  and  pus. 

The  catarrhal  gastritis  is  sometimes  of  severe  type. 

The  colitis  may  involve  either  the  lower  or  upper  part  of  the 
colon. 

In  any  one  case  either  one  or  several  of  these  inflammations 
may  be  present. 

Symptoms. — Few  diseases  offer  such  a  variety  in  their  symp- 
toms as  does  influenza.  Each  form  of  the  disease  closely  re- 
sembles one  of  the  ordinary  inflammations  or  diseases,  so  that 
errors  in  diagnosis  are  easy.  Often  we  would  be  unable  to  deter- 
mine the  character  of  the  attack  if  it  were  not  for  our  knowledge 
that  an  epidemic  of  influenza  is  prevailing.  The  ordinary  forms 
of  the  disease  are  as  follows  ; 

1.  Cases  characterized  by  fever  alone.  These  patients  com- 
plain little,  or  not  at  all,  of  headache  or  of  pains,  nor  do  they  have 
symptoms  referable  to  any  of  the  viscera.  But  every  day  the 
temperature  ranges  between  99°  and  103°  F.,  lower  in  the  morn- 
ing, higher  in  the  evening.  Some  of  the  patients  are  confined  to 
bed,  some  remain  in  the  house,  some  continue  at  their  work 
although  they  feel  miserably.  The  fever  lasts  a  few  days,  or 
even  two  or  three  weeks. 

2.  Cases  characterized  by  severe  pain  in  addition  to  the  fever. 
Tlie  pain  may  be  a  frontal  headache,  sometimes  of  great  severity; 
or  the  pain  may  be  referred  to  the  back,  the  limbs,  or  the  thorax. 
The  duration  of  the  disease  in  these  cases  is  usually  only  a  few 
days,  but  it  may  be  protracted  for  two  or  three  weeks. 

3.  Cases  characterized  by  great  bodily  and  mental  prostration 
in  addition  to  the  fever.  In  these  patients,  although  the  bodily 
depression  is  distressing,  the  mental  depression  is  much  worse. 
It  approaches  melancholia,  and  may  even  pass  into  it.  The 
fever  usually  only  lasts  a  few  days,  but  the  mental  and  bodily 
depression  may  continue  for  weeks  or  months. 


4IO  EPIDEMIC   INFLUENZA. 

4.  Cases  characterized  by  acute  catarrhal  inflammations  of 
the  nose,  pharynx,  tonsils,  or  larynx,  in  addition  to  the  fever. 
■In  these  patients  there  are  the  ordinary  local  symptoms  which 
belong  to  the  inflammations  of  these  mucous  membranes.  The 
disease,  as  a  rule,  runs  its  course  inside  of  a  week. 

5.  Cases  characterized  by  bronchitis,  which  may  be  developed 
at  any  time  in  the  course  of  the  influenza,  or  even  after  it  has 
subsided.  The  bronchitis  is  of  mild  type  ;  or  severe,  with  pro- 
fuse expectoration  of  mucus  with  more  or  less  blood  ;  or  severe 
with  venous  congestion  and  dyspnoea  ;  or  localized  in  some  one 
part  of  the  lung. 

6.  Cases  characterized  by  pneumonia.  In  children  the  type 
is  that  of  broncho-pneumonia,  in  adults  that  of  lobar  pneumonia. 
The  inflammation  of  the  lung  may  be  developed  at  any  time  in 
the  course  of  the  influenza,  or  after  it  has  subsided.  In  adults 
the  pneumonia  involves  one  or  more  lobes,  with  complete  or  in- 
complete hepatization,  often  with  congestion  out  of  proportion  to 
the  extent  of  hepatization.  In  nearly  all  the  cases  there  is  marked 
catarrhal  bronchitis  of  both  lungs.  The  invasion  is  either  like 
that  of  an  ordinary  lobar  pneumonia,  or  more  gradual.  The 
physical  signs  are  those  of  the  bronchitis  and  of  the  consolida- 
tion. The  course  of  the  temperature  is  not  like  that  of  an  ordi- 
nary pneumonia  ;  there  is  no  sudden  defervescence,  and  the  fever 
sometimes  continues  after  resolution  has  taken  place.  The  ex- 
pectoration is  usually  very  profuse,  more  like  that  of  bronchitis 
than  like  that  of  pneumonia.  There  is  in  many  cases  a  marked 
disposition  to  general  venous  congestion,  with  failure  of  the 
heart's  action.  The  duration  of  these  pneumonias  is  often  longer 
than  that  of  ordinary  lobar  pneumonia,  and  the  resolution  slower. 

7.  Cases  characterized  by  inflammation  of  the  pleura.  Dry 
pleurisies  involving  a  part  or  the  whole  of  the  pleura  on  one  side 
of  the  chest  are  not  uncommon.  They  occur  at  any  time  in  the 
course  of  the  influenza.  They  are  accompanied  with  pleuritic 
friction  sounds,  more  or  less  pain,  and  a  moderate  rise  of  tempera- 
ture. Pleurisies  with  the  production  of  fibrin  and  serum,  or 
with  fibrin,  serum,  and  pus,  are  usually  not  primary,  but  follow 
a  lobar  pneumonia. 

8.  Cases  characterized  by  acute  catarrhal  gastritis.  The  pa- 
tients suffer  from  gastric  pain,  nausea,  vomiting,  and  irritability 
of  the  stomach,  occasionally  with  vomiting  of  blood.  These 
symptoms  last  only  for  a  few  days  or  are  continued  for  several 


EPIDEMIC   INFLUENZA.  41  I 

weeks.  In  the  protracted  cases  the  emaciation  and  prostration 
are  extreme,  and  death  may  follow. 

9.  Cases  characterized  by  acute  catarrhal  colitis.  The  pa- 
tients have  colicky  pains,  loose,  diarrhoeal  passages,  a  moderate 
rise  of  temperature.  The  inflammation  runs  its  course  within 
two  weeks,  and  the  patients  are  not  at  any  time  very  sick. 

ID.  Cases  characterized  by  a  variety  of  rashes  in  the  skin. 

11.  Cases  which  behave  like  acute  cerebro-spinal  meningitis. 
The  patients  have  a  febrile  movement  which  runs  an  irregular 
course.  They  are  much  prostrated  and  look  very  ill.  They  have 
the  ordinary  cerebral  symptoms  :  headache,  photophobia,  pain, 
tenderness,  and  contraction  of  the  muscles  of  the  back  of  the 
neck,  vomiting,  delirium,  stupor,  general  convulsions. 

12.  The  cases  with  inflammation  of  the  sheaths  of  the  nerves 
suffer  from  a  good  deal  of  pain  along  the  course  of  the  nerves, 
followed  by  loss  of  power  and  atrophy  of  the  muscles. 

In  all  these  different. forms  of  influenza,  after  the  disease  has 
run  its  course,  the  patient  may  return  to  his  natural  health  within 
a  short  time.  Biit  one  of  the  distressing  features  of  the  disease 
in  many  cases  has  been  the  mental  and  bodily  depression,  which 
continues  for  weeks  and  months  after  the  acute  symptoms  have 
subsided. 

Treatment. — For  the  influenza  as  such  there  is  no  treatment. 

The  headache,  if  dependent  on  inflammation  of  the  frontal 
sinuses,  can  be  relieved  in  some  cases  by  local  applications  to  the 
nose.  For  the  general  headache  and  for  the  pains  in  other  parts 
of  the  body,  phenacetine,  given  in  five-grain  doses  every  two 
hours,  is  the  most  reliable  drug.  Of  less  efficacy  for  the  same 
purpose  areantifebrin,  antipyrin,  morphine,  and  the  bromides. 

The  inflammations  of  the  pharynx  and  tonsils  may  be  allevi- 
ated by  the  local  application  of  cocaine  and  the  internal  use  of 
aconite  and  the  salicylate  of  soda. 

For  the  bronchitis  and  pneumonia  we  employ  the  ordinary 
methods  of  treatment,  except  in  the  cases  with  a  disposition  to 
general  nervous  congestion  and  failure  of  the  heart's  action.  In 
these  cases  attention  to  the  condition  of  the  circulation  is  of  the 
greatest  consequence.  I  have  obtained  the  best  results  by  the 
combined  use  of  digitalin  \  milligm.,  aconitia  \  milligm.,  and 
whiskey. 

For  the  gastritis  we  employ  small  doses  of  morphine,  cocaine 
in  doses  of  ^V  ^^  ^  grain,  sulphonal  in  three-grain  doses  mixed 


412  ASIATIC    CHOLERA. 

with  the  milk.  No  matter  how  irritable  the  stomach  may  be,  I 
do  not  believe  it  is  wise  to  let  the  patients  go  for  many  days  with- 
out feeding  them  by  the  mouth.  Feeding  by  the  rectum  amounts 
to  very  little  for  these  patients. 

The  colitis  is  to  be  treated  by  rest  in  bed,  a  restricted  diet,  and 
a  little  opium. 

Asiatic  Cholera. 

An  infectious  disease  characterized  by  vomiting,  purging, 
cramps,  and  collapse. 

Causes  and  History. — The  natural  home  of  the  disease  is  in 
India,  where  it  has  been  endemic  for  an  unknown  length  of  time. 

The  first  epidemic  of  cholera  was  between  the  years  1817  and 
1823,  The  disease  prevailed  all  over  India,  and  extended  to 
Ceylon,  Burmah,  Siam,  Japan,  China,  Arabia,  Persia,  and  Syria. 

The  second  epidemic  was  between  the  years  1826  and  1837. 
It  spread  through  the  same  countries  as  in  the  first  epidemic, 
and  extended  into  Egypt,  Russia,  Germany,  Austria,  England, 
France,  Belgium,  the  Netherlands,  Canada,  the  United  States, 
Mexico,  Central  America,  Portugal,  Spain,  and  Italy. 

The  third  epidemic  was  from  1846  to  1863,  and  extended  over 
the  same  countries  as  were  involved  in  the  second  epidemic. 

The  fourth  epidemic,  from  1863  to  1875,  advanced  rapidly 
into  Europe,  and  was  very  extensive.  In  New  York  the  disease 
prevailed  from  1866  to  1867.  In  the  valley  of  the  Mississippi 
River  there  was  an  epidemic  in  1873. 

The  fifth  epidemic  began  in  1883,  and  is  not  yet  finished.  It 
has  as  yet  not  gone  over  as  many  countries  as  did  its  predecessors. 

The  disease  apparently  originates  only  in  India,  and  does  not 
occur  in  other  countries  unless  imported  into  them. 

When  the  disease  has  been  imported  into  any  country  it  is  not 
likely  to  spread,  unless  it  finds  there  conditions  favorable  to  its 
development.  These  favorable  conditions  are  :  the  uncleanly 
habits  of  the  population,  and  conditions  likelv  to  produce  diar- 
rhoea. 

The  pathogenic  micro-organism  of  the  disease  was  described 
by  Koch  in  1884.  It  is  called  the  "Spirillum  cholerse  asiaticae," 
or  popularly  the  "  Comma  Bacillus." 

The  micro-organism  grows  and  multiplies  rapidly  within  the 
intestines,  and  acts  there  as  a  local  irritant.  It  is  discharged  with 
the  faeces,  rarely  with  the  vomit.     It  is  not  present  in  the  urine, 


ASIATIC   CHOLERA.  413 

the  breath,  or  the  sputa,  it  is  not  given  off  from  the  surface  of  the 
body.  Outside  the  human  body  the  organisms  live,  grow,  and 
multiplv  on  moist  surfaces  and  in  dirty  water. 

They  are  destroyed  by  drying,  heat,  boiling,  mineral  acids, 
corrosive  sublimate,  and  carbolic  acid. 

To  communicate  the  disease  the  organisms  discharged  in  the 
faeces  of  the  siclc  must  be  taken  into  the  alimentary  canals  of  the 
healthy. 

Lesions. — i.  Those  who  die  during  the  stages  of  invasion  or 
collapse. 

The  temperature  of  the  body  may  rise  after  death.  The 
rigor  mortis  begins  early  and  lasts  for  a  long  time.  The  skin  is 
of  a  dusky-gray  color  ;  the  lips,  eyelids,  fingers,  and  toes  are 
livid  ;  the  cheeks  are  fallen  in  ;  the  skin  of  the  fingers  is  shrunken 
and  wrinkled. 

The  sinuses  of  the  dura  mater  are  filled  with  tliick  blood. 
The  pia  mater  may  be  oedematous,  or  ecchymotic,  or  infiltrated 
with  fibrin. 

The  pleura  may  be  coated  with  fibrin.  The  lungs  are 
shrunken  and  anaemic. 

The  peritoneum  may  be  coated  with  fibrin. 

The  stomach  may  show  the  lesions  of  catarrhal  gastritis. 

The  small  intestines  are  anaemic  or  congested  ;  the  solitary 
and  agminated  glands  may  be  swollen  ;  the  mucous  membrane  is 
soft. 

The  colon  is,  in  some  epidemics,  the  seat  of  croupous  inflam- 
mation. 

The  kidneys  show  the  lesions  of  acute  degeneration. 

2.  Those  who  die  during  the  stage  of  reaction.  The  bodies 
do  not  present  the  same  appearance  of  desiccation,  and  more  in- 
flammatory changes  are  found. 

The  larynx,  bronchi,  lungs,  pleura,  stomach,  or  intestines  may 
be  inflamed. 

Symptoms. — In  the  first  stage  of  cholera  the  disease  follows  one 
of  two  forms  : 

1.  The  patients  are  suddenly  attacked  with  pains  in  the  abdo- 
men, purging,  vomiting,  and  cramps.  These  symptoms  last  for 
half  an  hour,  or  several  hours.  Then  the  patients  either  die  or 
go  on  to  the  second  stage  of  the  disease. 

2.  The  patients  have  an  ordinary,  moderate  diarrhoea,  with 
loss  of  appetite,  nausea,  and  prostration.     These  symptoms  con- 


414  ASIATIC    CHOLERA. 

tinue  for  several  days.  Then  the  patients  recover,  or  go  on  to 
the  second  stage  of  the  disease. 

In  the  second  stage  of  the  disease  there  are  frequent,  large 
passages  of  fluid,  looking  like  rice-water,  from  the  bowels.  There 
is  vomiting  of  food,  of  drink,  and  of  a  rice-water  fluid  like  that 
which  is  passed  from  the  intestines.  The  patients  suffer  from 
constant  thirst,  from  pains  in  the  abdomen,  and  from  painful 
cramps  in  the  muscles  of  the  legs.  The  temperature  falls  below 
the  normal,  the  pulse  is  rapid  and  feeble,  the  face  is  shrunken 
and  pinched,  the  urine  is  scanty.  The  second  stage  lasts  for  from 
two  to  fifteen  hours,  then  the  patients  may  get  better,  or  they 
may  pass  into  the  third  stage  of  the  disease. 

In  the  third  stage  of  the  disease,  the  stage  of  collapse,  the 
vomiting  and  purging  continue,  but  are  not  as  frequent.  The 
cramps  and  pains  also  continue.  The  heart's  action  is  so  feeble 
and  rapid  that  the  radial  pulse  cannot  be  felt.  The  shrunken 
and  livid  appearance  of  the  skin  and  face  is  more  marked  ;  the 
prostration  is  extreme  ;  the  urine  is  suppressed  ;  the  temperature 
falls  to  about  94°  ;  the  patients  are  constantly  thirsty,  restless 
and  sleepless,  but  the  intelligence  remains  clear.  This  stage 
seldom  lasts  over  twenty-four  hours.  A  great  many  of  the 
patients  die  during  this  stage,  a  few  recover,  a  few  go  on  to  the 
fourth  stage. 

In  the  fourth  stage,  that  of  reaction,  the  skin  continues  to  feel 
cold,  but  the  temperature  rises  to  99°  or  100°.  The  purging  and 
vomiting  cease  ;  the  radial  pulse  can  again  be  felt ;  the  breathing 
is  rapid  ;  the  urine  is  suppressed;  the  patients  are  semi-coma- 
tose. One  or  other  of  the  inflammations  of  the  pia  mater,  larynx, 
lungs,  stomach,  or  intestines  is  developed,  or  abscesses  are 
formed  in  the  parotid,  or  in  other  places.  Very  few  of  the 
patients  who  pass  into  this  stage  recover. 

Treatment. — The  most  important  part  of  the  treatment  of 
cholera  is  its  prevention.  It  is  evident,  when  we  remember  the 
way  in  which  the  poison  of  cholera  is  eliminated  from  the  body, 
the  way  in  which  it  is  taken  into  the  body,  and  the  ways  in  which 
it  can  be  destroyed,  that  it  ought  not  to  be  difficult  to  prevent 
the  spread  of  the  disease.  It  is  only  necessary  to  disinfect  the 
faeces,  and  to  see  that  infected  faeces  are  not  introduced  into  the 
mouth  with  water,  food,  etc. 

During  the  stage  of  premonitory  diarrhoea  the  patients 
should  be  kept  in  bed.     The  bowels  should  be  first  emptied  and 


YELLOW   FEVER.  4l5 

then  full  doses  of  salol,  or  beta  naphthol  bismuth,  are  given,  to 
which  a  little  opium  may  be  added.  Or  large  injections  of  tannin 
may  be  given  by  the  rectum.     The  formula  is  : 

Infusion  of  Chamomile  Flowers 2,000  parts 

Ac.   Tannic 20  parts 

Gum-arabic 30  parts 

Tr.  Opii 2  parts 

Two  quarts  of  the  solution  at  the  temperature  of  100°  F. 
should  be  allowed  to  flow  in  slowly  from  a  fountain  syringe. 

During  the  second  stage  of  the  disease  the  patient  can  be 
made  more  comfortable  by  hypodermic  injections  of  morphine. 
The  vomiting  may  be  alleviated  by  cocaine,  chloroform,  and  acid- 
ulated drinks.  Alcoholic  stimulants  are  usually  required.  To 
make  up  for  the  loss  of  blood  serum  we  may  use  warm  baths,  or 
the  warm  rectal  injections  of  tannin,  or  subcutaneous  injections 
of  warm  solutions  of  chloride  of  sodium,  80  grammes,  carbonate 
of  sodium,  6  grammes,  water,  2  litres.  This  solution  is  used  at 
the  temperature  of  110°  F.,  and  about  thirty  ounces  can  be  in- 
troduced under  the  skin  at  one  time. 

Yellow  Fever. 

Causes. — Yellow  fever  is  endemic  in  the  West  India  Islands, 
in  some  places  on  the  shores  of  the  Gulf  of  Mexico,  and  on  the 
west  coast  of  Africa. 

From  these  places  the  disease  has  been  carried  to  different 
places  in  the  United  States,  Central  America,  South  America,  and 
Spain,  producing  epidemics  in  these  places. 

We  are  still  ignorant  of  the  micro-organism  which  probably 
constitutes  the  poison  of  the  disease  ;  nor  do  we  know  how  it  is 
eliminated  from,  or  taken  into,  the  body. 

The  poison  of  the  disease  requires  a  temperature  of  70°  F.  for 
its  growth  and  development.  It  is  capable  of  remaining  in  cloth- 
ing, bedding,  ships,  etc.,  and  retaining  its  vitality  for  a  long  time. 

Cities  are  more  liable  to  the  disease  than  country  places  ;  dirty 
cities  are  more  liable  than  clean  ones. 

The  inhabitants  of  countries  where  the  disease  is  endemic 
are  less  liable  to  it  than  are  strangers.  One  attack  confers  a  less 
liability  to  a  second  attack. 

Lesions. — There  is  well-marked  jaundice  of  the  skin  and  other 
tissues.     There  are  often  ecchymoses  in  the  skin. 


41 6  YELLOW   FEVER. 

The  wall  of  the  heart  is  in  the  condition  of  granular  and  fatty 
degeneration. 

The  lungs  are  congested. 

The  stomach  contains  more  or  less  black  fluid,  its  mucous 
membrane  is  congested.     The  intestines  may  contain  blood. 

The  liver  shows  the  changes  of  acute  degeneration.  The  liver- 
cells  are  swollen,  coarsely  granular,  or  disintegrated. 

In  the  kidneys  we  find  the  changes  belonging  to  an  intense 
form  of  acute  degeneration.  The  kidneys  are  large,  the  renal 
epithelium  is  degenerated,  or  dead,  the  tubes  contain  .cast  matter. 

The  period  of  incubation  of  yellow  fever  varies  from  twenty-four 
hours  to  several  weeks  ;  usually  it  only  lasts  for  a  few  days. 

Symptoms. — Occasionally  there  is  a  prodromic  period,  lasting 
for  several  days,  marked  by  headache,  giddiness,  and  loss  of  ap- 
petite, but  more  frequently  the  invasion  is  sudden,  marked  with 
chill,  or  sometimes  with  general  convulsions. 

During  the  first  stage  the  temperature  runs  up  rapidly, 
reaching  103°  F.  to  110°  F.  by  the  end  of  the  first  twenty-four 
hours.  The  pulse  is  a  full  pulse  of  80  to  120,  but  sometimes  is 
very  slow.  There  are  headache,  pains  in  the  back,  restlessness, 
sleeplessness,  delirium,  vomiting  of  food,  constipation.  The 
face  is  flushed,  the  tongue  is  coated,  the  urine  contains  albumin 
and  casts. 

Exceptionally,  during  the  first  stage  the  fever  is  moderate, 
there  is  no  delirium,  but  little  prostration,  and  the  patients  are 
not  confined  to  bed. 

The  first  stage  lasts  for  from  two  to  six  days. 

During  the  second  stage  of  the  disease  the  temperature  and 
the  pulse  fall  to  the  normal,  and  the  patients  are  better  in  every 
way.  Some  then  go  on  to  convalescence  ;  others,  after  one  or 
two  days,  go  on  to  the  third  stage. 

During  the  third  stage  the  vomiting  of  food  continues,  and  is 
succeeded  by  the  vomiting  of  a  blackish  fluid,  the  so-called  black 
vomit.  The  patients  become  jaundiced,  are  dull  and  stupid,  and 
complain  of  pain  in  the  abdomen.  There  may  be  bleeding  from 
the  nose,  mouth,  intestines,  and  kidneys,  or  into  the  skin  and 
connective  tissue. 

The  urine  is  very  scanty  or  suppressed. 

The  conditions  of  alternating  stupor  and  delirium  are  very 
marked. 

The  third  stage  lasts  for  from  one  to  three  days. 


TYPHUS   FEVER.  41/ 

The  mortality  of  the  disease  is  very  high. 

Treaiinent. — The  preventive  treatment  consists  in  isolating  the 
patients,  and  in  destroying  or  disinfecting  the  clothes,  bedding, 
etc. 

The  treatment  consists  principally  in  an  attempt  to  alleviate 
SA'-mptoms. 

The  bichloride  of  mercury,  combined  with  soda,  has  been  rec- 
ommended for  the  treatment  of  the  disease  itself. 

Cocaine,  given  by  the  mouth,  is  used  as  a  remedy  for  the 
vomiting. 

Typhus  Fever. 

Synonyms. — Typhus  exanthematicus.  Putrid,  camp,  jail,  hos- 
pital, ship,  or  spotted  fever. 

History  and  Causes. — Typhus  fever  is  endemic  in  Ireland,  Eng- 
land, and  Russia.  In  other  countries  it  occurs  from  time  to  time 
in  epidemics.  It  has  regularly  accompanied  wars,  famine,  and 
the  crowding  of  prisons,  ships,  and  houses  with  ill  nourished  and 
ill-aerated  human  beings. 

Epidemics  have  occurred  in  this  way  in  all  parts  of  Europe. 

In  the  United  States  there  have  been  a  few  epidemics,  mostly 
in  the  cities  on  the  sea-coast. 

In  New  York  the  last  severe  epidemic  was  in  1863  to  1864. 
In  1882  there  were  a  few  cases  of  typhus  in  the  city,  but  hardly 
an  epidemic. 

Although  no  age  is  exempt  from  the  disease,  the  maximum 
liabilitv  is  between  the  ages  of  fifteen  and  twenty  years. 

The  disease  is  apparently  not  influenced  by  the  seasons  of  the 
year  or  by  atmospheric  conditions. 

The  poison  of  the  disease  has  not  as  yet  been  demonstrated. 
It  seems  to  be  given  off  from  the  surface  of  the  sick  body,  to 
float  in  the  air,  and  to  contaminate  bedding,  clothing,  etc.  So 
we  find  that  the  disease  is  communicated  from  person  to  person, 
and  by  clothing,  bedding,  and  rooms.  Nurses  and  physicians 
very  often  contract  the  disease.  It  is  much  more  easily  taken  by 
persons  who  are  poor,  badly  fed,  and  over-crowded.  Few  people 
escape  the  disease  if  they  are  sufficiently  exposed.  It  seems  to 
be  most  contagious  from  the  end  of  the  first  week  up  to  the  time 
of  convalescence. 

The  accumulation  of  patients  in  the  same  room  renders  the 
disease  more  contaafious. 


4l8  TYPHUS   FEVER. 

It  is  an  exceptional  tiling  for  any  person  to  suffer  from  more 
than  one  attack  of  the  disease. 

Period  of  Incubation. — The  symptoms  may  appear  a  few  hours 
after  exposure.  Usually  they  appear  between  eight  and  twelve 
days  after  exposure  ;  rarely,  if  ever,  after  a  longer  period  than 
twenty-one  days. 

Lesions. — Tlie  only  characteristic  lesion  of  the  disease  is  the 
eruption.  But  after  death  a  number  of  secondary  lesions  may  be 
found. 

There  may  be  acute  meningitis.  There  may  be  catarrhal  or 
croupous  inflammation  of  the  pharynx  and  larynx. 

In  the  lungs  we  find  bronchitis,  broncho-pneumonia,  hypo- 
static congestion,  or  oedema. 

In  the  heart  there  may  be  degeneration  of  the  muscular 
fibres. 

The  liver  and  spleen  mav  be  the  seat  of  acute  degeneration. 

In  the  ileum  the  agminated  glands  may  be  a  little  swollen,  as 
may  also  the  mesenteric  glands. 

The  voluntary  muscles  in  different  parts  of  the  body  may  be 
the  seat  of  acute  degeneration. 

In  the  kidneys  we  find  the  lesions  of  the  mild  or  severe  forms 
of  acute  degeneration,  or  those  of  acute  exudative  nephritis. 

Symptoms. — During  the  first  week  there  is  a  general  venous 
congestion  of  the  face  and  conjunctiva,  and  a  dull,  apathetic  ex- 
pression. During  the  second  week  the  patients  look  like  per- 
sons in  the  third  week  of  typhoid  fever. 

The  tongue  is  at  first  coated  and  moist,  later  dry  and  brown. 

Cerebral  symptoms  are  marked — restlessness,  sleeplessness, 
delirium,  and  stupor.  The  delirium  is  attended  with  illusions,  is 
often  violent,  and  is  worse  at  night.  It  may  mark  the  invasion 
of  the  disease,  it  may  simulate  an  attack  of  acute  mania,  or  it 
may  not  be  developed  until  the  second  week.  It  is  always  a 
dangerous  delirium,  and  one  which  needs  constant  watching. 
As  the  delirium  subsides  the  stupor  increases,  but  without  nat- 
ural sleep. 

Sometimes  the  patients  develop  the  condition  called  "  coma 
vigil."  They  are  unconscious,  with  open  eyes,  a  rapid  and  feeble 
pulse,  shallow  breathing,  and  a  cold  skin. 

Headache  and  pains  in  the  back  and  limbs  are  early  and  fre- 
quent symptoms. 

Vomiting  and  tympanites  are  not  very  common. 


TYPHUS   FEVER.  419 

Constipation  is  the  rule  until  the  close  of  the  disease,  but 
there  may  be  diarrhoea  throughout. 

The  prostration  is  marked,  but  during  the  first  week  may  be 
less  evident  by  reason  of  the  active  delirium. 

The  eruption  is  very  constant,  but  varies  in  its  extent.  It  ap- 
pears from  the  fourth  to  the  seventh  day,  and  lasts  from  seven  to 
ten  days.  There  is  only  a  single  crop.  It  appears  on  the  arms, 
legs,  and  trunk.  It  is  in  the  form  of  irregular,  rounded,  pinkish 
blotches  resembling  the  eruption  of  measles.  The  spots  become 
darker  with  time,  or  may  be  quite  dark  from  the  first.  There  is 
also  sometimes  a  deep  mottling  in  the  skin,  and  sometimes  a  gen- 
eral erythematous  blush.  From  the  eighth  to  the  tenth  day  there 
may  be  small  ecchymoses  in  the  blotches  of  the  eruption.  After 
the  eruption  has  disappeared  there  is  more  or  less  desquamation. 

The  temperature  rises  rapidly,  and  reaches  its  maximum  be- 
tween the  second  and  tenth  day,  usually  between  the  fourth  and 
seventh  day,  reaching  104°  to  106°  F.  At  first  the  temperature 
is  nearly  continuous,  by  the  seventh  to  the  tenth  day  there  are 
morning  remissions.  In  favorable  cases,  about  the  fourteenth 
day  the  temperature  suddenly  falls. 

The  pulse  is  at  first  about  100  and  full,  later  it  becomes  rapid 
and  feeble.  Or  it  may  be  rapid  and  feeble  from  the  first,  or  slow 
and  feeble  throughout  the  disease. 

The  heart's  action  in  the  second  week  becomes  feeble,  and  its 
first  sound  less  distinct. 

The  breathing  is  rapid,  and  in  the  second  week  is  rendered 
worse  by  the  hypostatic  congestion,  oedema,  bronchitis,  or 
broncho-pneumonia. 

The  kidneys  become  the  seat  of  acute  degeneration,  or  acute 
exudative  nephritis,  with  diminution  in  the  quantity  of  urine,  and 
more  or  less  albumin  and  casts. 

Muscular  tremor,  twitching  of  the  muscles  of  the  face,  sub- 
sultus  tendinum,  picking  at  the  bed-clothes,  and  automatic  move- 
ments of  the  arms  and  legs  may  be  developed  during  the  second 
week. 

General  convulsions  sometimes  occur  in  the  second  week, 
with  the  severer  forms  of  nephritis. 

In  the  later  stages  of  the  disease  there  is  retention  of  urine, 
incontinence  of  faeces,  and  difficulty  in  swallowing. 

Severe  catarrhal  or  croupous  inflammations  of  the  pharynx 
or  larynx  are  sometimes  developed. 


420  TYPHUS   FEVER. 

Acute  meningitis,  with  an  exaggeration  of  the  cerebral  symp- 
toms belonging  to  the  typhus  fever  is  a  dangerous   complication. 

There  may  be  bleeding  from  the  mucous  membranes  into  the 
skin,  the  serous  membranes,  and  the  muscles.  The  most  danger- 
ous hemorrhages  are  those  from  the  stomach. 

Often  there  is  suppuration  of  one  or  both  parotid  glands. 

Not  infrequently  there  is  thrombosis  of  one  or  both  femoral 
veins,  less  frequently  of  the  sinuses  of  the  dura  mater. 

Bed-sores  are  easily  formed  and  very  troublesome. 

Course  of  the  Disease. — There  may  be  a  prodromic  period 
marked  by  general  malaise,  headache,  vertigo,  and  loss  of  appe- 
tite. 

The  invasion  of  the  disease  is  usually  sudden,  marked  by 
chills,  fever,  headache,  pains  in  the  back  and  limbs,  loss  of  appe- 
tite, vomiting,  restlessness,  sleeplessness,  and  prostration.  From 
the  fourth  to  the  seventh  day  the  eruption  appears. 

In  the  second  week  come  the  alternating  delirium  and  stupor, 
the  dry  tongue,  the  typhoid  state,  the  feeble  heart-action,  the 
complicating  lesions. 

In  the  favorable  cases,  about  the  fourteenth  day  the  tempera- 
ture falls,  the  patients  begin  to  sleep,  and  then  convalescence 
commences. 

The  regular  duration  of  the  disease  is  fourteen  days.  Mur- 
chison,  in  500  cases  of  recovery,  gives  the  subsidence  of  the  dis- 
ease as  between  the  seventh  and  the  twentieth  days  ;  in  three- 
fourths  of  the  cases  between  the  thirteenth  and  sixteenth  days. 
In  100  fatal  cases  death  took  place  between  the  sixth  and  the 
twentieth  days.  There  are  some  very  bad  cases  which  only  live 
a  few  hours. 

Seqiielce. — In  some  cases  a  condition  of  mental  imbecility  con- 
tinues for  several  weeks. 

In  some  patients  aphasia  or  hemiplegia  follow  the  disease. 

There  may  be  paralysis  of  groups  of  the  voluntary  muscles. 

The  prognosis  is  always  grave.  The  disease  is  especially  fatal 
in  elderly  persons  and  in  those  enfeebled  by  starvation.  Some 
epidemics  are  more  fatal  than  others. 

Treatment.— 'T.\\^  patients  are  to  be  isolated  as  far  as  possible. 
It  is  important  not  to  accumulate  many  patients  in  the  same 
room  or  building,  and  to  provide  for  the  largest  possible  quan- 
tity of  fresh  air.  The  clothing  and  bedding  must  be  burned  or 
-thoroughly  disinfected. 


TYPHOID    FEVER.  421 

In  the  treatment  of  the  disease  the  most  important  points  are 
the  very  large  admission  of  fresh  air  and  the  nursing.  Alcoholic 
stimulants  in  large  quantities  are  often  of  service,  but  must  be 
given  witli  judgment. 

Typhoid  Fever. 

An  infectious  disease  characterized  by  fever  and  the  develop- 
ment of  lesions  in  the  lymphatic  glands  of  the  intestine  and 
mesentery. 

Lesions.  —  i.   The  characteristic  lesions: 

By  the  second  day  of  the  disease  the  solitary  and  agminated 
glands  of  the  intestine  are  swollen,  and  the  swelling  increases 
during  the  first  week.  In  the  second  week  there  is  more  or  less 
necrosis  of  the  swollen  glands,  with  ulceration  or  sloughing.  In 
the  fourth  week  there  is  cicatrization  of  the  ulcers. 

The  swelling  of  the  glands  may  be  moderate  and  not  go  on  to 
ulceration  or  sloughing  ;  it  may  be  greater  with  the  formation  of 
small  ulcers  ;  it  may  be  very  great  with  extensive  necrosis  and 
sloughing. 

A  number  of  the  glands  are  attacked  at  the  same  time,  or  first 
those  in  the  lower  part  of  the  ileum  are  involved,  and  later  those 
farther  up. 

The  lesions  may  be  confined  to  the  agminated  glands,  or  in- 
volve also  the  solitary  glands,  or  extend  to  the  solitary  glands  of 
the  colon. 

The  cases  vary  as  to  the  number  of  glands  involved,  the  de- 
gree of  the  swelling,  the  size  and  depth  of  the  ulcers. 

The  mesenteric  glands  are  usually  only  swollen,  sometimes 
they  suppurate.    They  may  excite  a  local  or  a  general  peritonitis. 

2.  The  accessory  lesions  : 

The  spleen  is  usually  large  and  soft.  In  the  ileum  and  colon 
there  may  be  catarrhal  or  croupous  inflammation. 

There  may  be  peritonitis  from  perforation  of  the  intestinal 
ulcers,  from  the  diseased  mesenteric  glands,  or  without  discov- 
erable cause. 

The  softened  spleen  may  rupture.  The  hepatic  cells  may  be 
the  seat  of  acute  degeneration. 

The  kidneys  exhibit  the  lesions  of  acute  degeneration,  or  of 
acute  exudative  nephritis. 

The  heart-walls  are  often  soft  and  flabby.    The  parotid  glands 


422  TYPHOID   FEVER. 

may  suppurate.  In  the  pharynx  and  larynx  there  may  be  catar- 
rhal or  croupous  inflammation. 

The  lungs  are  often  the  seat  of  hypostatic  congestion,  of 
bronchitis,  of  broncho-pneumonia,  or  of  lobar  pneumonia. 

There  may  be  acute  meningitis.  The  peripheral  nerves  may 
be  the  seat  of  an  acute  degeneration. 

There  is  degeneration,  and  sometimes  rupture,  of  the  volun- 
tary muscles. 

There  may  be  thrombosis  of  the  femoral  veins,  or  of  the 
sinuses  of  the  dura  mater. 

The  characteristic  micro-organism  of  the  disease  is  a  bacillus 
which  is  found  in  the  intestinal  lesions  and  in  the  contents  of  the 
intestines.  It  is  also  found  in  the  mesenteric  glands,  the  spleen, 
the  liver,  the  kidneys,  and  the  blood. 

The  bacilli  are  discharged  from  the  typhoid  patient  princi- 
pally with  the  faeces.  They  can  live  for  a  long  time  outside  of 
the  body,  under  favorable  conditions. 

They  are  most  frequently  taken  into  the  body  with  contami- 
nated water  and  milk. 

The  course  of  the  growth  of  the  bacilli  seems  to  be  as  fol- 
lows :  They  are  taken  into  the  stomach,  pass  into  the  small  in- 
testine, and  remain  there  without  giving  any  symptoms  for 
about  two  weeks.  Then  they  begin  to  find  their  way  into  the 
lymphatic  glands  in  the  wall  of  the  small  intestine.  As  soon  as 
this  happens  the  patients  have  symptoms  more  or  less  severe,  ac- 
cording to  the  extent  of  the  infection  of  the  glands.  At  a  later 
time  the  bacilli  find  their  way  to  the  mesenteric  glands,  the 
spleen,  and  other  parts  of  the  body.  The  effect  of  the  presence 
of  the  bacilli  on  the  lymphatic  glands  in  the  intestine  is  to  pro- 
duce inflammation,  or  necrosis,  or  both.  The  growth  of  the 
bacilli  is  attended  with  the  evolution  of  a  poison  which  is  the 
direct  cause  of  the  symptoms  of  the  disease. 

Etiology. — Typhoid  fever  prevails  in  the  form  of  local  epi- 
demics, as  an  endemic  disease,  and  in  the  form  of  isolated  cases. 

The  history  of  a  local  epidemic  is  apt  to  be  as  follows  :  A  person 
already  suffering  from  typhoid  fever  goes  to  a  house  in  the  coun- 
try, or  in  a  village  where  the  disease  has  not  previously  existed. 
He  goes  through  the  disease  at  this  place.  His  faeces  are  put  in 
a  privy  vault,  or  cesspool  ;  his  soiled  clothes  and  bedding  are 
washed  without  being  disinfected.  The  persons  who  handle  and 
wash  the  soiled  clothes  often  contract  the  disease.     The  contents 


TYPHOID   FEVER.  423 

of  the  infected  privy  or  cesspool  after  a  time  drain  into  the 
adjoining  well  ;  most  of  the  persons  who  drink  this  contaminated 
water  have  typhoid  fever.  The  persons  living  in  the  same  village 
who  do  not  drink  the  contaminated  water,  nor  handle  the  in- 
fected clothes,  do  not  have  the  disease. 

Occasionally  the  disease  is  given  by  milk  which  has  been 
contaminated  by  the  infected  water. 

In  some  places  typhoid  fever  is  an  endemic  disease,  prevail- 
ing year  after  year.  When  this  is  the  case  the  disease  is  regu- 
larly much  more  prevalent  in  the  autumn  months,  and  varies  in 
different  years  as  to  the  number  of  cases  and  the  type  of  the  dis- 
ease. 

The  most  puzzling  cases  to  account  for  are  the  isolated  cases 
which  occur  from  time  to  time  in  cities. 

The  disease  seems  to  protect  against  itself,  and  the  same  per- 
son rarely  suffers  from  two  attacks. 

Symptotns. — The  regular  duration  of  the  disease  is  four  weeks, 
and  to  each  week  belongs  its  ovvn  set  of  symptoms. 

The  regular  course  of  the  temperature  is  as  follows  : 

During  the  first  week  the  temperature  rises  regularly  from 
day  to  day,  always  with  a  lower  temperature  in  the  morning  and 
a  higher  temperature  in  the  evening,  but  with  each  day  the  dif- 
ference between  the  morning  and  evening  temperature  becomes 
less. 

During  the  second  week  the  temperature  is  always  high,  with 
but  little  difference  between  the  morning  and  evening  tempera- 
ture. 

In  the  third  week  the  morning  temperature  begins  to  fall,  the 
evening  temperature  remaining  the  same. 

In  the  fourth  week  the  morning  temperature  falls  still  lower, 
then  the  evening  temperature  falls,  until  finally  both  get  down  to 
the  normal. 

The  maximum  temperature  is  reached  between  5  and  12  p.m. 
The  minimum  temperature  is  recorded  between  6  and  8  a.m. 

Variations  from  the  Regular  Temperature. — In  the  first  week  the 
invasion  may  be  ushered  in  by  a  chill,  and  similar  chills  may  be 
repeated  for  several  days.  The  temperature  may  fall  to  the  nor- 
mal for  as  long  as  forty-eight  hours. 

The  temperature  may  rise  rapidly  and  reach  104°  F.  by  the 
first,  second,  or  third  day. 

In  the  second  week  there   may  be   no  difference  between  the 


424  TYPHOID    FEVER. 

morning  and  evening  temperature.  There  may  be  an  unusual 
difference  between  the  morning  and  evening  temperature.  The 
morning  temperature  may  be  the  highest.  There  may  be  ir- 
regular rises  and  falls  of  temperature  from  day  to  day. 

In  the  third  week  the  temperature  may  be  higher  than  at  any 
time  in  the  disease.  The  temperature  may  suddenly  fall  to  the 
normal  and  not  rise  again,  or  it  may  fall  and  then  go  on  again. 
There  may  be  irregular  changes  in  the  temperature  from  day  to 
day. 

In  the  fourth  week  the  temperature  may  fall  to  the  normal, 
then  rise  and  go  on  for  from  five  to  ten  weeks. 

In  the  third  and  fourth  weeks  the  morning  temperature  may 
fall  to  the  normal  or  below  it,  while  the  evening  temperature 
runs  up  to  105°  or  106°  F.  This  makes  one  think  of  a  complica- 
tion by  malarial  poisoning.  But  it  may  occur  with  nothing  but 
the  typhoid  fever. 

Complicating  inflammations  change  the  course  of  the  tem- 
perature. 

Hemorrhages  from  the  bowels  are  often  followed  by  a  marked 
fall  of  temperature.  — ~- 

An  evening  fever,  sometimes  followed  by  sweating,  may  be 
continued  after  the  fourth  week. 

In  fatal  cases  the  temperature  usually  continues  high  up  to 
death.  But  sometimes  the  temperature  is  not  higher  than  100° 
to  102°  F.  for  several  days  before  death. 

The  height  of  the  temperature  is  regularly  in  proportion  to 
the  severity  of  the  disease,  but  in  some  fatal  cases  the  tempera- 
ture is  never  very  high. 

The  course  of  the  temperature  is  changed  by  malarial  poison- 
ing. 

If  the  patient  is  regularly  bathed  the  course  of  the  tempera- 
ture is  very  much  modified. 

The  pulse  regularly  follows  the  temperature.  During  the 
first  week  it  is  from  80  to  100  and  full  ;  during  the  second  and 
third  weeks  it  is  more  rapid,  more  feeble,  or  dicrotic. 

The  feeble  pulses  are  usually  rapid,  but  sometimes  slow. 

The  disease  may  run  its  entire  course  with  a  pulse  between 
60  and  80. 

Cerebral  Symptoms. — Headache,  restlessness,  irritability,  and 
sleeplessness  belong  to  the  first  week  of  the  disease. 

In  the  second  week  the  patients  are  in  a  condition  of  apathy. 


TYPHOID    FEVER.  42$ 

In  the  third  week  are  regularly  developed  alternating  delirium 
and  stupor, 

A  violent  delirium  may  come  on  in  the  first  days  of  the  dis- 
ease. 

The  characteristic  apathy  may  be  absent,  even  in  fatal  cases. 

There  are  some  patients  in  whom  the  headache  is  very  severe 
at  first,  and  in  whom  there  is  later  developed  a  stupor  which  con- 
tinues until  death.  These  cases  resemble  cerebro-spinal  men- 
ingitis. 

The  eruption  is  in  the  form  of  small,  isolated,  rose-colored, 
lenticular  spots,  slightly  elevated,  and  disappearing  on  pressure. 
It  appears  on  the  front  of  the  chest  and  abdomen,  sometimes  on 
the  back.  There  are  only  a  few  spots,  or  many.  It  appears  be- 
tween the  seventh  and  twelfth  days,  exceptionally  between  the 
fourth  and  twentieth  days.  There  are  successive  crops  of  erup- 
tion, so  that  it  lasts  from  seven  to  twenty-one  days,  but  it  may 
only  last  for  from  two  to  four  days. 

Relapses  are  marked  by  a  fresh  eruption.  Spots  may  con- 
tinue to  appear  after  convalescence  has  commenced. 

In  some  cases  no  eruption  can  be  demonstrated. 

The  tongue  is  at  first  moist,  with  a  broad  strip  of  white  fur 
down  the  centre.  In  the  milder  cases  the  tongue  remains  moist 
throughout  the  disease,  in  the  more  severe  cases  it  becomes  dry, 
brown,  and  fissured.  Or  the  tongue  remains  clean,  but  becomes 
dry,  glazed,  and  fissured. 

Nausea  and  vomiting  are  often  present  during  the  first  week. 
Later  in  the  disease  there  may  be  vomiting  from  the  tympanites, 
from  the  retention  of  food  in  the  stomach,  or  from  peritonitis. 

Some  distention  of  the  intestines  with  gas  is  usually  present  ; 
marked  distention  is  an  unfavorable  symptom  ;  extreme  disten- 
tion may  so  interfere  with  the  action  of  the  heart  and  lungs  as  to 
cause  alarming  pulmonary  and  cardiac  symptoms. 

Diarrhoea  is  a  regular  symptom  of  the  disease,  several  loose, 
fecal  passages  every  day,  of  the  appearance  of  pea-soup.  Such 
a  diarrhoea  may  be  one  of  the  first  symptoms  ;  it  may  not  come 
on  until  the  third  or  fourth  week  ;  it  may  not  begin  until  after 
the  patient  has  taken  a  purgative  ;  it  may  last  for  a  few  days  or 
throughout  the  disease.  A  severe  diarrhoea  is  an  unfavorable 
symptom.  In  some  epidemics  but  few  patients  have  any  diar- 
rhoea at  all. 

Hemorrhage  from  the  intestines  occurs  in  a  moderate  num- 


426  TYPHOID    FEVER. 

ber  of  the  cases.     During  the  first  week  there  may  be  moderate 
bleeding  from  the  congested  mucous  membrane. 

The  more  important  bleedings  are  from  the  ulcers  in  the  in- 
testines. They  occur  most  frequently  in  the  third  and  fourth 
weeks,  but  are  sometimes  seen  as  early  as  the  second  week, 
sometimes  not  until  after  the  fourth  week,  or  even  in  conva- 
lescence. The  hemorrhages  are  small  or  large,  single  or  re- 
peated. Large  hemorrhages  are  regularly  followed  by  a  tem- 
porary fall  of  temperature.  The  hemorrhages  are  usually,  but 
not  always,  preceded  by  diarrhoea.  Such  hemorrhages  are 
sometimes  fatal,  and  it  is  even  possible  for  a  patient  to  bleed  to 
death  in  this  way  without  the  escape  of  any  blood  from  the 
rectum. 

There  is  often  epistaxis,  either  early  or  late  in  the  disease, 
single  or  repeated,  rarely  so  profuse  as  to  be  dangerous. 

The  eyes  in  the  third  week  may  become  somewhat  insensible 
to  light,  with  dilated  pupils. 

Ringing  and  buzzing  sounds  in  the  ears  may  be  complained 
of  in  the  first  week  ;  in  the  third  and  fourth  weeks  there  may  be 
more  or  less  deafness. 

Subsultus  tendinum,  muscular  tremor,  picking  at  the  bed- 
clothes, the  involuntary  passage  of  faeces,  and  retention  of  urine 
belong  to  the  third  and  fourth  weeks. 

The  condition  of  the  urine  varies  with  that  of  the  kidneys. 
The  most  common  lesion  is  a  mild  form  of  acute  degeneration, 
with  a  little  albumin  and  a  few  casts  in  the  urine.  In  the  pro- 
tracted cases,  however,  the  degeneration  of  the  epithelium  be- 
comes very  marked.  Less  frequently  there  is  an  acute  exudative 
nephritis,  with  diminution  in  the  quantity  of  urine,  numerous 
casts,  and  considerable  quantities  of  albumin. 

Bronchitis  may  be  developed  at  any  time  in  the  disease.  It 
is  usually  confined  to  the  larger  tubes,  and  it  is  not  very  severe. 

Broncho-pneumonia  is  a  much  more  serious  complication. 
It  may  be  developed  at  any  time  in  the  course  of  the  disease. 
When  it  occurs  in  the  first  week,  it  is  often  very  difficult  to  tell 
whether  the  patients  have  pneumonia  or  typhoid  fever  compli- 
cated by  pneumonia. 

Catarrhal  pharyngitis  is  very  often  present,  croupous  pharyn- 
gitis but  seldom. 

Catarrhal  or  croupous  laryngitis,  ulcers  of  the  larynx,  and 
oedema  of  the  g-lottis  are  occasionallv  met  with. 


TYPHOID    FEVER.  427 

^Suppurative  inflammation  of  the  parotid  glands  belongs  to 
the  later  periods  of  the  disease. 

During  the  third  and  fourth  weeks,  sometimes  earlier,  there 
may  be  thrombosis  of  the  veins.  The  veins  most  frequently 
affected  are  the  femoral  veins  and  the  sinuses  of  the  dura  mater. 
The  formation  of  a  thrombus  is  attended  with  a  rise  of  tempera- 
ture and  increased  prostration.  With  thrombosis  of  the  femoral 
vein  there  is  pain  and  tenderness  over  the  vein  and  oedema  of 
the  leg. 

With  thrombosis  of  the  sinuses  of  the  dura  mater  there  is  loss 
of  consciousness  or  hemiplegia,  according  to  the  position  of  the 
thrombus. 

From  thrombosis  of  the  femoral  vein  patients  usually  recover, 
but  thrombosis  of  the  sinuses  of  the  dura  mater  is  usually  fatal. 

In  some  patients  the  disposition  to  bleeding  from  the  differ- 
ent mucous  membranes  is  very  marked. 

Catarrhal  or  croupous  inflamm.ation  of  the  colon  may  ac- 
company or  follow  typhoid  fever. 

Perforation  of  the  intestinal  ulcers  is  a  very  fatal  lesion.  It 
happens  most  frequently  in  the  third,  fourth,  and  fifth  weeks. 
It  may  happen  in  the  second  week,  or  after  convalescence  is 
established.  It  is  most  common  in  severe  cases,  but  may  occur 
in  the  very  mild  ones.  It  is  followed  by  the  symptoms  of  shock 
and  the  development  of  a  general  peritonitis. 

Peritonitis  is  produced  not  only  by  perforation,  but  also  by 
an  extension.of  the  inflammation  from  the  w-all  of  the  intestines, 
by  inflammation  of  the  mesenteric  glands,  and  by  infarctions  of 
the  spleen.  It  usually  gives  well-marked  symptoms  of  acute 
general  peritonitis,  and  is  very  fatal. 

Course  of  the  Disease. — The  period  of  incubation  is  said  to  vary 
between  two  days  and  four  weeks ;  the  ordinary  period  is  two 
weeks. 

The  method  of  invasion  of  the  symptoms  varies  considerably 
in  different  cases.  This  difference  seems  to  depend  upon  differ- 
ences in  the  growth  of  the  typhoid  bacilli  and  the  rapidity  with 
vv^hich  they  find  their  way  into  the  wall  of  the  intestine,  the 
spleen,  and  the  rest  of  the  body. 

In  a  considerable  number  of  cases  one  or  two  weeks  elapse 
before  the  patients  feel  sick  enough  to  go  to  bed.  They  are 
more  or  less  miserable,  with  headache,  sleeplessness,  nausea,  an 
irregular  febrile  movement,  and  sometimes  diarrhoea.     This  seems 


428  TYPHOID    FEVER. 

to  mean  that  the  bacilli  are  growing  in  the  intestine,  are  begin- 
ning to  find  their  way  into  its  wall,  but  that  the  quantity  of 
poison  evolved  by  their  growth  is  but  small. 

The  more  ordinary  invasion  is  for  the  patients  to  feel  sick 
enough  to  go  to  bed  within  the  first  twenty-four  hours.  Then 
for  about  two  weeks  they  get  steadily  worse.  The  temperature 
becomes  gradually  higher  and  more  continuous,  the  patients  suf- 
fer from  epistaxis,  pharyngitis,  headache,  vertigo,  apathy,  sleep- 
lessness, pain  in  the  neck,  back,  and  abdomen,  a  coated  tongue, 
loss  of  appetite,  nausea,  vomiting,  diarrhoea,  or  constipation. 
This  would  correspond  with  a  sudden  and  extensive  invasion  of 
the  lymphatic  glands  of  the  intestine,  a  gradual  but  continuous 
invasion  of  other  parts  of  the  body,  with  a  very  considerable 
evolution  of  poison. 

Occasionally  it  happens  that  while  the  patient  becomes  quite 
ill,  with  a  rise  of  temperature,  during  the  first  twenty-four  hours, 
yet  for  the  ten  succeeding  days  there  are  intermissions  of  low 
temperature  and  subsidence  of  symptoms.  After  this  the  patient 
settles  down  into  the  regular  course  of  the  disease.  This  would 
correspond  with  interruptions  in  the  growth  and  invasion  of  the 
bacilli. 

It  may  also  happen  that  the  patient  begins  with  the  regular 
invasion  of  a  mild  typhoid  and  goes  on  to  be  moderately  sick  for 
two  weeks.  At  the  end  of  that  time  the  symptoms  change  for 
the  worse  and  the  disease  runs  a  severe  course.  This  would 
seem  to  indicate  a  second  infection  more  severe  than  the  first. 

The  invasion  of  the  symptoms  may  be  unusually  rapid  and 
severe.  The  temperature  runs  up  to  104°  F.,  with  chills,  within 
the  first  twenty-four  hours.  Here  the  infection  is  evidently  very 
rapid  and  extensive. 

There  are  irregular  invasions  for  which  we  are  unable  to 
account,  and  which  simulate  the  invasions  of  other  diseases. 

In  some  patients  the  first  symptoms  resemble  those  of  cere- 
bro-spinal  meningitis  :  headache,  pain,  and  stiffness  in  the  back 
of  the  neck,  violent  delirium  or  general  convulsions. 

In  some  patients  the  complicating  inflammations  of  the  chest 
are  very  marked.  It  may  be  a  bronchitis,  or  a  broncho-pneu- 
monia, or  a  pleurisy. 

Or  instead  of  this  there  is  an  acute  catarrhal  gastritis  with 
vomiting  and  diarrhoea  ;  or  an  acute  nephritis  with  the  charac- 
teristic changes  in  the  urine. 


TYPHOID   FEVER.  429 

During  the  first  week  there  are  the  characteristic  tempera- 
ture, epistaxis,  pharyngitis,  headache,  vertigo,  apathy,  sleepless- 
ness, pain  in  the  neck,  back,  and  abdomen,  the  coated  tongue, 
loss  of  appetite,  nausea,  vomiting,  diarrhoea,  or  constipation, 
blood  with  the  stools,  prostration. 

It  is  often  difficult  to  fix  the  date  of  the  first  day  of  the  dis- 
ease. The  ordinary  rule  is  to  take  the  first  day  when  the  patient 
takes  to  his  bed. 

During  the  second  week  of  the  disease  there  are  the  charac- 
teristic temperature,  the  increased  rapidity  and  feeblenes  of  the 
heart's  action,  more  apathy,  delirium,  noises  in  the  ears,  deaf- 
ness, the  dry  tongue,  the  eruption,  diarrhoea  or  constipation, 
tympanites. 

At  the  end  of  the  second  week  the  patient  may  die,  he  may 
become  convalescent,  or  the  disease  may  continue. 

During  the  third  week  there  are  the  characteristic  tempera- 
ture, the  heart's  action  more  rapid  and  feeble,  the  cerebral  symp- 
toms more  marked,  the  full  development  of  the  typhoid  state, 
bleeding  from  the  intestinal  ulcers,  peritonitis,  involuntary  pas- 
sage of  faeces,  retention  of  urine. 

In  the  fourth  week,  if  the  case  is  a  favorable  one,  there  is  a 
gradual  abatement  of  all  the  symptoms,  and  convalescence  com- 
mences in  the  fifth  week.  If  the  disease  is  to  be  protracted,  the 
symptoms  of  the  fourth  week  will  continue  like  those  of  the 
third,  or  there  will  be  an  improvement  for  one  or  two  days,  and 
then  the  disease  goes  on  again. 

The  relapses  of  typhoid  fever  are  a  curious  feature  of  the 
disease.  They  seem  to  be  a  fresh  attack  of  the  disease  produced 
by  a  fresh  infection  from  the  patient  himself.  Each  relapse  is 
attended  with  a  new  eruption  and  a  repetition  of  the  symptoms 
of  the  disease. 

The  intermission  between  the  end  of  the  original  attack  and 
the  beginning  of  the  relapse  is  from  three  to  twenty-five  days,  the 
ordinary  period  is  from  ten  to  fourteen  days.  The  relapse  lasts 
from  seven  to  thirty-nine  days,  the  ordinary  duration  is  from  ten 
to  fourteen  days.  A  single  relapse  is  not  uncommon,  more 
common  in  some  epidemics  than  in  others.  A  second  relapse  is 
comparatively  rare. 

The  Irregular  Cases. — i.  The  Mild  Form.  The  pulse  and 
temperature  remain  nearly  or  quite  normal.  The  patients  have 
irregular  feelings  of  heat  and  cold,  headache,  irritability,  sleep- 


430  TYPHOID    FEVER. 

lessness,  loss  of  appetite,  and  general  prostration  and  discomfort, 
but  are  not  sick  enough  to  be  in  bed.  The  bowels  continue  regu- 
lar, or  there  may  be  constipation  or  diarrhoea. 

In  some  of  the  patients  bronchitis  is  a  prominent  symptom, 
in  others  nausea  and  vomiting. 

The  patients  remain  in  this  condition  for  three  or  four  weeks. 
They  are  liable  to  hemorrhage  from  the  intestine,  to  perforation 
of  the  intestinal  ulcers,  and  to  attacks  of  delirium, 

2.  The  Short  Form.  The  whole  duration  of  the  disease  is  only 
two  weeks. 

In  some  of  the  patients  there  is  a  considerable  rise  of  tem- 
perature, of  which  the  rise  and  fall  are  alike  rapid. 

In  other  cases  there  is  no  fever,  only  lassitude,  headache,  and 
loss  of  appetite. 

3.  The  Protracted  Form.  Instead  of  running  its  course 
within  four  weeks  the  disease  continues.  The  fever  and  other 
symptoms  go  on  with  little  change,  and  the  patient  remains  ill 
for  five,  six,  seven,  eight,  nine,  ten,  eleven,  or  even  twelve  weeks, 
as  the  case  may  be. 

4.  The  Afebrile  Form.  Typhoid  fever  may  run  its  entire  course 
with  evening  temperatures  of  not  over  99°,  and  morning  tempera- 
tures below  98°,  and  yet  it  is  evident  that  the  patients  ai-e  really 
ill.     They  often  feel  exceedingly  weak,  with  a  feeble  heart-action. 

In  1870  there  was  an  epidemic  of  typhoid  fever  in  the  German 
army  around  Paris.  The  cases  were  characterized  by  an  abun- 
dant eruption,  great  prostration,  violent  delirium,  marked  stupor, 
but  slight  abdominal  symptoms,  and  temperatures  not  over  ioo°, 
or  not  above  98°.  The  disease  was  moderately  fatal,  and  after 
death  the  ordinary  lesions  were  found. 

5.  Typhoid  Fever  Complicated  by  Malarial  Poisoning,  It  is 
possible  for  a  patient  to  be  infected  at  the  same  time  by  the  poi- 
sons of  typhoid  fever  and  malaria.  He  will  then  go  through  a 
disease  with  lesions  and  symptoms  belonging  to  both  these  mor- 
bid states. 

Convalescence  begins  regularly  in  the  fifth  week.  If  uncompli- 
cated it  progresses  steadily,  but  yet  it  is  months  before  the  patient 
is  really  like  himself. 

The  convalescence  may  be  interrupted  in  several  ways  : 

An  afternoon  fever  may  continue  for  a  number  of  days. 

There  may  be  severe  pain  in  the  back,  apparently  due  to  in- 
flammation of  the  periosteum  of  the  vertebrae. 


TYPHOID   FEVER.  43 1 

The  mind  may  remain  dull,  apathetic,  and  feeble  for  days  or 
weeks. 

There  may  be  hemiplegia,  dependent  on  thrombosis  of  the 
sinuses  of  the  dura  mater  ;  or  paralyses  of  groups  of  muscles  due 
to  changes  in  the  peripheral  nerves. 

There  may  be  hemorrhage  from  intestinal  ulcers  which  have 
not  healed,  or  perforation  with  peritonitis. 

There  may  be  a  catarrhal  gastritis,  with  pain,  nausea,  and 
vomiting. 

There  may  be  catarrhal  or  croupous  inflammation  of  the  colon, 
with  the  symptoms  of  dysentery. 

There  may  be  rapid  and  irregular  heart-action. 

The  patients,  after  beginning  to  convalesce,  may  make  no 
real  progress  and  die  in  an  emaciated  and  feeble  condition. 

The  Prognosis  of  typhoid  fever  is  a  very  uncertain  one. 

Cases  which  are  at  first  mild  may  later  turn  out  very  badly. 

The  cases  with  high  temperatures  and  with  nearly  continuous 
temperatures  are  always  severe. 

A  profuse  and  continued  diarrhoea  is  a  serious  symptom. 

Very  marked  distention  of  the  intestines  with  gas  belongs  to 
the  bad  cases. 

Hemorrhages  from  intestinal  ulcers,  even  if  they  are  not  of 
themselves  fatal,  belong  to  the  severe  cases  of  the  disease. 

Perforation  of  an  intestinal  ulcer,  or  peritonitis  from  any 
cause,  is  nearly  uniformly  fatal. 

Severe  muscular  tremor  indicates  the  existence  of  deep  intes- 
tinal ulcers. 

Epistaxis  is  not  often  of  itself  serious,  but  its  early  and  re- 
peated occurrence  belongs  to  the  more  severe  cases. 

The  sooner  the  patient  goes  to  bed  after  the  invasion  of  the 
disease,  the  better  the  prognosis. 

The  mortality  varies  in  different  epidemics,  and  in  different 
years,  in  places  where  the  disease  is  endemic. 

Treatment. — i.     To  prevent  the  disease. 

The  faeces  should  be  received  into  a  vessel  containing  a  suffi- 
cient quantity  of  disinfecting  fluid,  and  thoroughly  mixed  with 
this  fluid  before  being  emptied  into  the  common  receptacle. 

The  following  are  efficient  disinfecting  fluids  : 

5 .      Bichloride  of  mercury 3  ij. 

Acid  hydrochloric 3  x. 

Water I  gallon. 


432  TYPHOID   FEVER. 

^ .   Bichloride  of  mercury 3  ij. 

Permanganate  of  potash 3  ij . 

Water i  gallon. 

M. 

5 .  Chloride  of  lime 3  iv. 

Water I  gallon. 

M. 

All  the  soiled  clothes  are  to  be  soaked  in  one  of  these  solu- 
tions, or  steamed  before  they  are  washed. 

Persons  travelling  or  living  in  localities  where  typhoid  fever 
exists  must  be  very  careful  about  drinking  the  water  of  the  place. 

Treatment  of  the  Disease. — The  patients  are  to  be  put  to  bed 
and  placed  on  a  fluid  diet  as  soon  as  possible. 

During  the  first  week  the  patients  are  troubled  by  headache, 
restlessness,  irritability,  and  pains  in  the  stomach.  These  symp- 
toms can  be  alleviated  by  sulphonal,  opium,  and  the  bromides, 
but  these  drugs  are  to  be  used  sparingly  and  with  caution. 

Vomiting  can  usually  be  relieved  by  attention  to  the  food. 

If  the  bowels  are  constipated,  they  should  be  moved  once  in 
three  days  by  an  enema  ;  if  there  is  too  much  diarrhoea,  it  must 
be  checked  to  some  extent  by  opium.  Cold  bathing  often  stops 
the  diarrhoea. 

The  milder  nose-bleeds  require  no  treatment  ;  for  the  more 
severe  ones  it  is  necessary  to  plug  the  nostrils. 

If  the  pharyngitis  is  troublesome,  local  applications  of  cocaine 
give  relief. 

The  mouth  and  tongue  are  to  be  kept  clean. 

The  heart's  action  during  the  first  week  usually  continues 
good. 

As  regards  the  temperature,  the  following  propositions  may 
be  stated  : 

The  temperature  as  such  does  not  add  to  the  dangers  of  the 
disease,  nor  require  treatment. 

The  systematic  use  of  cold  baths  of  the  temperature  of  65°  F. 
lowers  the  mortality  of  the  disease,  but  not  because  it  lowers  the 
temperature.  High  temperatures  may  make  the  patients  uncom- 
fortable, and  it  may,  therefore,  be  proper  to  give  antipyretic 
drugs,  although  these  drugs  do  not  increase  the  probability  of 
recovery. 

In  the  second  week  the  heart's  action  often  begins  to  fail  and 
calls  for  the  use  of  alcoholic  stimulants. 

If  there  is  excessive  distention  of  the  intestines   by  gas,  we 


TYPHOID   FEVER.  433 

employ  hot  or  cold  applications  over  the  abdomen,  the  internal 
administration  of  turpentine  or  asafoetida,  placing  a  soft- rubber 
tube  in  the  rectum,  or  cold  bathing. 

For  the  bleeding  from  the  intestinal  ulcers,  we  give  opium 
and  a,pply  cold  over  the  abdomen. 

For  excessive  muscular  tremor  we  give  opium,  asafoetida,  or 
the  compound  spirits  of  ether. 

In  the  third  week  we  have  to  care  for  the  retention  of  urine, 
the  formation  of  bed-sores,  the  suppurative  inflammation  of  the 
parotid  glands,  the  thrombosis  of  the  veins,  and  the  perito- 
nitis. 

For  the  disease  itself  the  most  efficient  treatment  is  by  cold 
bathing.  In  carrying  out  this  treatment  the  best  results  are  ob- 
tained by  adhering  closely  to  the  method  as  laid  down  by  Brand. 
Once  every  three  hours,  if  the  temperature  in  the  rectum  reaches 
103°  F.,  the  patient  is  to  be  immersed  in  a  bath  of  the  temperature 
of  70°  F.  In  this  bath  he  is  to  be  kept  for  ten  or  fifteen  minutes, 
during  which  time  the  surface  of  the  entire  body  is  constantly 
rubbed.  After  the  bath  the  patient  takes  either  an  alcoholic 
stimulant  or  a  hot  drink.  The  best  results  are  obtained  when 
the  bathing  is  begun  during  the  first  week  of  the  disease. 

When  the  bathing  cannot  be  carried  out,  the  treatment  by  in- 
testinal antisepsis  may  be  tried. 

The  method  of  Burney  Yeo  is  as  follows  :  In  a  12-ounce  bottle 
30  grains  of  chlorate  of  potash  and  40  minims  of  hydrochloric 
acid  are  mixed.  After  the  bottle  is  filled  with  gas  it  is  filled  up 
with  water.  To  12  ounces  of  this  solution,  24  grains  of  quinine 
and  r  ounce  of  syrup  of  oranges  are  added.  The  dose  of  this  is 
I  ounce  at  intervals  of  from  one  to  four  hours. 

Another  method  is  to  give  sulphate  of  magnesia  in  repeated 
doses  so  as  to  produce  moderate  purgation,  the  patient  at  the 
same  time  drinking  large  quantities  of  water. 

Still  another  plan  is  that  of  giving  considerable  doses  of  salol, , 
or  of  carbolic  acid. 

The  plan  of  Dr.  Woodbridge  is  as  follows  :  The  treatment  is 
begun  with  tablets  each  of  which  contains 

Podophyllum  resin ^4o  grain. 

Calomel i^g  grain. 

Guiacol  carbonate iV  grain. 

Menthol iV  grain. 

Eucalyptol q.  s. 


434  RELAPSING   FEVER. 

One  tablet  is  given  every  15  minutes  during  the  first  24  hours, 
and  in  larger  doses  if  necessary  during  the  second  24  hours,  until 
during  this  and  the  succeeding  24  hours  not  less  than  five  or  six 
free  evacuations  of  the  bowels  are  secured  during  each  of  these 
periods.  On  the  third  or  fourth  day  of  treatment  the  following 
tablets  are  used  : 

Podophyllum  resin y^  grain. 

Calomel tb-  grain. 

Guiacol  carbonate \  grain. 

Menthol i^g-  grain. 

Thymol iV  grain. 

Eucalyptol q.  s. 

A  tablet  is  given  at  intervals  of  one  or  two  hours.  Both  these 
tablets  are  given  at  longer  intervals  as  the  temperature  falls. 

About  the  fourth  or  fifth  day  of  treatment  the  employment  of 
the  following  capsules  is  commenced  : 

Guiacol  carbonate 3  grains. 

Thymol i  grain. 

Menthol i  grain. 

Eucalyptol 5  minims. 

One  capsule  every  three  hours,  alternating  with  the  tablets. 

Convalescence. — The  principal  point  in  a  normal  convalescence 
is  to  manage  the  transition  from  fluid  to  solid  food.  In  my 
opinion  this  transition  should  usually  not  be  delayed  for  more 
than  a  few  days,  and  the  best  solid  food  to  begin  with  is  beef  or 
mutton. 

When  the  typhoid  fever  seems  to  have  run  its  course,  and  yet 
an  afternoon  fever  continues,  there  may  be  an  advantage  in  the 
use  of  quinine,  and  in  these  patients  we  do  not  always  wait  for  a 
normal  temperature  before  we  begin  the  use  of  solid  food. 

Relapsing  Fever. 

Synonyms.  —  Famine  fever.  Spirillum  fever.  Typhus  recur- 
rens. 

History  and  Causes. — Epidemics  of  this  disease  have  occurred 
since  1739,  in  Ireland,  England,  and  Scotland.  From  1863  to 
1873  there  were  epidemics  in  Russia  and  Germany,  In  India 
there  were  epidemics  from  1877  to  1880.  In  New  York  there 
were  epidemics  in  1847,  ^"d  in  1869  to  1870. 

The  disease  occurs  regularly  in  epidemics.     It  has  often  fol- 


RELAPSING   FEVER.  435 

lowed  famines,  and  is  especially  prevalent  among  the  poor  and 
destitute.  It  is  very  contagious,  but  we  do  not  know  the  exact 
way  in  which  the  disease  is  transmitted  from  one  person  to  an- 
other. One  attack  does  not  protect  against  subsequent  attacks. 
As  a  rule,  epidemics,  when  they  have  run  their  course,  disappear 
completely,  but  in  a  few  places  the  disease  has  become  endemic. 
Lesions. — The  pharynx  may  be  the  seat  of  catarrhal  or  croup- 
ous inflammation. 

The  stomach  may  be  congested,  or  there  may  be   extravasa- 
tions of  blood  in  its  mucous  membrane. 

The  small  and  large  intestine  may  be  the  seat  of  catarrhal  or 
croupous  inflammation. 

The  liver  may  be  the  seat  of  acute  degeneration  and  in- 
creased in  size. 

The  spleen  is  large  and  soft  ;  it  may  contain  infarctions  ;  it 
may  rupture. 

There  may  be  a  general  peritonitis.  The  muscular  fibres  of 
the  wall  of  the  heart  may  be  degenerated. 

The  larynx  may  be  the  seat  of  catarrhal  or  of  croupous  in- 
flammation. 

Bronchitis,  broncho-pneumonia,  lobar  pneumonia,  and  pleu- 
risy, are  not  infrequent. 

In  the  kidneys  acute  degeneration  of  mild,  or  of  severe,  type 
is  regularly  present. 

The  characteristic  micro-organism  of  the  disease  is  a  spirillum 
which  is  found  in  large  numbers  in  the  blood.  It  is  found  most 
constantly  in  the  febrile  stage  of  the  disease.  The  blood  con- 
taining the  spirilla,  when  inoculated  in  monkeys,  reproduces  the 
disease.  It  is,  however,  not  known  how  in  the  human  subject 
the  micro-organism  is  eliminated  from  the  body  of  the  sick 
person,  or  how  it  is  transferred  from  one  person  to  another. 

The  period  of  incubation  of  the  disease  seems  to  vary  from 
a  few  hours  to  twenty-one  days. 

Symptoms. — The  invasion  of  the  disease  is  regularly  sudden. 
There  are  chills,  headache,  pains  in  the  back  and  limbs,  and 
prostration.  Very  soon  the  temperature  rises,  and  soon  runs  up 
to  from  104°  to  108°  F.  The  headache  is  worse,  the  tongue  is 
coated,  there  is  vomiting  of  food,  of  greenish  or  of  coffee-ground 
matters. 

The  patients  cannot  sleep,  there  are  pain,  tenderness,  and 
enlargement  of  the  liver  and  spleen. 


436  THE   EXANTHEMATA   FEVER. 

Between  the  third  and  tenth  day,  usually  on  the  fifth  or 
seventh,  there  is  an  abrupt  fall  of  temperature,  with  sweating? 
epistaxis,  diarrhoea,  or  hemorrhages  from  the  bowels  or  stomach. 
For  about  seven  days  the  cessation  of  fever  continues,  and  then 
there  is  a  relapse,  with  all  the  symptoms  of  the  first  attack.  The 
relapse  lasts  for  from  one  to  seven  days,  usually  for  three.  There 
may  be  a  second,  third,  or  fourth  relapse.  Rarely,  there  is  no 
relapse  at  all. 

There  is  no  characteristic  eruption,  but  in  some  epidemics 
roseola,  or  a  reddish  mottling  of  the  skin,  or  petechial  spots  are 
present. 

The  bowels  are  sometimes  constipated,  sometimes  loose. 

Jaundice  may  appear  in  the  first  paroxysm,  in  the  second,  or 
in  both.     It  belongs  to  the  severe  cases. 

The  urine  varies  with  the  severity  of  the  acute  degeneration 
of  the  kidneys.  There  may  be  a  good  deal  of  pain  in  the 
muscles  and  joints  during  the  disease,  or  in  convalescence. 

Rarely,  there  are  general  convulsions  at  the  time  of  the  fall 
of  temperature. 

Complications  and  Sequelce. — There  may  be  laryngitis,  bron- 
chitis, pleurisy,  lobar  pneumonia,  rupture  of  the  spleen,  acute 
colitis,  or  peritonitis. 

During  convalescence  there  may  be  inflammation  of  the 
ciliary  body  or  choroid  coat  of  the  eye  ;  or  paralysis  of  groups  of 
muscles. 

Prognosis. — The  mortality  varies  with  the  epidemics  and  with 
the  previous  condition  of  the  patients. 

The  bad  cases  are  characterized  by  hemorrhages  from  the 
stomach  and  bowels,  cerebral  symptoms,  suppression  of  urine, 
pneumonia,  peritonitis,  dysentery,  and  collapse  at  the  time  of  the 
fall  of  temperature. 

Treatment. — The  prophylactic  treatment  is  difficult  on  account 
of  our  ignorance  of.  the  way  in  which  the  poison  of  the  disease 
is  eliminated  from  the  body. 

Of  the  disease  itself,  the  treatment  consists  wholly  in  the 
nursing  and  the  alleviation  of  symptoms. 

The  Exanthemata. 

The  members  of  this  group  of  the  infectious  diseases  have 
several  features  in  common  : 


SMALL-POX.  437 

Each  one  of  them  has  a  characteristic  form  of  inflammation 
of  the  skin. 

Each  has  its  own  specific  poison,  which  seems  to  be  given  off 
from  the  skin  and  inhaled  with  the  breath. 

They  do  not  originate  from  outside  causes,  but  each  new  case 
is  derived  from  a  preceding  case  of  the  same  disease. 

Each  of  them  has  a  regular  period  of  incubation,  of  invasion, 
and  of  eruption. 

In  each  of  them  one  attack  protects  more  or  less  completely 
against  subsequent  attacks  of  the  same  disease. 

Small-pox. 

Small-pox,  or  variola,  seems  to  be  one  of  the  oldest  diseases 
known  to  us.  There  are  accounts  of  the  disease  going  back  to 
the  sixth  century  ;  and  from  the  Middle  Ages  to  the  time  of  the 
introduction  of  vaccination  the  disease,  both  in  its  epidemic  and 
endemic  forms,  was  very  prevalent  and  terribly  fatal. 

Etiology. — Although  small-pox  possesses  an  exceedingly  active 
poison,  we  are  still  ignorant  of  its  exact  nature.  It  is  probable 
that  it  is  a  micro-organism,  it  is  certain  that  it  is  contained  in  the 
fluid  within  the  pustules.  The  disease  can  be  directly  inocu- 
lated from  one  person  to  another.  Its  poison  can  float  in  the 
air,  can  remain  in  rooms  and  clothing,  can  retain  its  vitality  for 
long  periods  of  time,  and  can  be  carried  in  clothing,  etc.,  for 
thousands  of  miles.  The  susceptibility  to  the  disease  at  all  ages 
is  very  great,  so  that  very  few  unvaccinated  persons  escape  after 
exposure.  One  attack  of  the  disease  regularly  protects  against 
subsequent  attacks. 

The  period  of  incubation  usually  lasts  for  from  ten  to  .fifteen 
days,  although  either  longer  or  shorter  periods  are  occasionally 
observed.  During  this  period  the  patients  may  seem  to  be  per- 
fectly well ;  or  they  may  suffer  from  loss  of  appetite,  sleepless- 
ness, and  general  malaise. 

The  period  of  invasion  lasts  for  two  or  three  days,  rarely  it 
extends  to  four,  five,  or  six  days.  The  invasion  is  sudden,  with 
distinct  chills  or  continued  chilliness  and  a  rapid  rise  of  tem- 
perature up  to  from  103°  to  107°  F.  The  pulse  becomes  rapid 
and  full,  the  breathing  is  rapid,  there  is  marked  prostration,  the 
tongue  is  coated,  the  patients  vomit,  they  may  have  general  con- 
vulsions, they  may  become  delirious.     A   severe   aching  pain  in 


438  SMALL-POX. 

the  head  and  back  are  so  constant  and  intense  that  they  help  to 
distinguish  small-pox  from  the  other  infectious  diseases.  The 
mucous  membrane  of  the  tonsils  and  pharynx  may  be  congested 
and  dusky.  The  disease  may  prove  fatal  during  the  stage  of 
invasion. 

On  the  second  and  third  days  of  the  period  of  invasion  are 
seen  in  some  patients  the  so-called  variolous  rashes,  which  are 
not  to  be  confounded  with  the  regular  eruption  of  the  disease. 
These  rashes  appear  in  the  form  of  points,  streaks,  or  diffuse 
blushes,  of  red,  purple,  or  brownish-red  color.  They  are  made 
paler  by  pressure,  but  do  not  show  the  white  streak  made  by 
drawing  the  finger-nail  over  the  inflamed  skin,  which  is  seen  in 
scarlet  fever.  The  surfaces  involved  are  either  not  raised  at  all, 
or  but  slightly  raised  above  the  general  level  of  the  skin.  The 
regions  chiefly  involved  are  the  groin,  the  inner  face  of  the 
thighs,  and  the  hypogastric  region,  the  axilla,  the  pectoral  region, 
and  the  inner  surface  of  the  arm  ;  but  the  rash  may  involve  any 
part  of  the  skin.  The  rash  may  be  mottled  by  hemorrhagic, 
petechial  spots,  or  by  large  wheals  ;  it  may  appear  on  one  part 
of  the  body,  disappear,  and  recur  in  another  place. 

The  Period  of  Eruption. — The  eruption  appears  first  on  the 
face  and  scalp,  and  then  extends  so  as  to  involve  a  large  part 
of  the  skin  and  of  the  mucous  membranes.  At  first  it  is  in  the 
form  of  rounded,  red  spots.  By  the  second  day  of  the  eruption 
these  spots  have  become  papules  ;  by  the  sixth  day  they  have 
changed  into  umbilicated  vesicles;  by  the  eighth  day  the  vesicles 
are  changed  into  pustules.  As  the  vesicles  are  changing  into 
pustules  the  adjacent  skin  and  mucous  membranes  become  con- 
gested, swollen,  and  infiltrated  with  inflammatory  products. 

As  the  eruption  first  appears  the  temperature  falls  and  the 
constitutional  symptoms  subside. 

As  the  vesicles  change  into  pustules  and  the  skin  becomes 
inflamed,  the  temperature  rises,  the  pulse  becomes  more  rapid, 
the  patients  suffer  a  great  deal  from  the  condition  of  the  skin 
and  mucous  membranes,  the  prostration  is  very  great,  the 
patients  are  either  stupid  or  delirious.  In  this  condition  the 
patients  remain  for  from  three  to  eight  days. 

Then,  in  the  favorable  cases,  the  temperature  falls,  the  in- 
flammation of  the  skin  subsides,  all  the  symptoms  abate,  the 
pustules  dry  up,  scabs  and  crusts  are  formed,  and  finally  the 
scabs  fall  off  and  leave  cicatricial  depressions  in  the  skin.     Five 


SMALL-POX.  439 

or  six  weeks  are  required  for  the  subsidence  of  the  changes  in 
the  skin  and  the  complete  disappearance  of  all  the  constitutional 
symptoms. 

The  confluent  form  of  small-pox  is  ushered  in  by  a  relatively 
short  period  of  incubation,  followed  by  a  severe  invasion.  The 
chills  are  violent,  the  pains  in  the  head  and  back  are  most  severe, 
the  temperature  runs  up  to  from  105°  to  110°  F.;  the  symptoms 
subside  but  little  as  the  eruption  appears. 

The  papules  of  the  eruption  are  large  and  very  close  together. 
The  vesicles  and  pustules  are  so  close  to  each  other  that  they 
coalesce,  the  skin  is  intensely  inflamed  and  horribly  swollen. 
The  mucous  membranes  are  much  swollen,  coated  with  mucus, 
pus,  and  false  membranes,  and  sometimes  gangrenous.  The 
stench  arising  from  the  patient  is  intolerably  fetid  and  pervading. 
The  extensive  suppuration  of  the  skin  is  attended  with  the  evi- 
dences of  septic  poisoning  :  the  heart's  action  becomes  rapid  and 
feeble,  delirium  or  stupor  prevails,  and  the  prostration  is  ex- 
treme. The  patients  are  liable  to  complicating  inflammations  of 
the  pericardium,  pleura,  bronchi,  lungs,  stomach,  intestines,  and 
kidneys. 

The  malignant  form  of  small-pox  is  said  to  follow  one  of  three 
types  : 

The  first  form  has  a  short  period  of  incubation,  during  which 
the  patients  suffer  from  a  good  deal  of  malaise  and  lumbar  pain. 
On  the  fourth  day  there  is  a  high  temperature  with  a  rapid  pulse, 
speedily  followed  by  a  deep  purplish-red  staining  of  the  face, 
neck,  trunk,  and  extremities,  the  skin  thus  affected  being  slightly 
tumid  and  quite  dry.  At  this  time  the  eruption  resembles  that 
of  black  measles.  Then  papules  are  formed  which  rapidly  change 
into  large  purpuric  patches.  The  mucous  surfaces  become  dry, 
cracked,  and  covered  with  crusts.  There  are  hemorrhages 
from  the  larynx,  bronchi,  intestines,  viscera,  muscles,  and  serous 
membranes.  The  prostration  from  the  first  is  extreme,  the 
patients  soon  become  unconscious,  and  death  takes  place  within 
one  or  two  days. 

In  the  second  form  the  period  of  incubation  is  also  short.  On 
the  fourth  day  the  skin  is  swollen  and  indurated  in  consequence 
of  the  presence  of  numerous  firm  papules  very  closely  set  to- 
gether. These  soon  become  larger  and  infiltrated  with  blood. 
Regular  pustules  are  sometimes  formed  here  and  there,  or  parts 
of  the  skin  may  become  gangrenous.     Delirium,  stupor,  an  in- 


440  SMALL-POX. 

tense  fever,  and  a  rapid  and  feeble  pulse  continue,  and  the 
patients  die  within  four  or  five  days. 

In  the  third  form  there  is  little  rise  of  temperature,  but  the 
prostration  and  cerebral  symptoms  are  equally  marked  ;  th6  regu- 
lar eruption  is  absent  and  replaced  by  an  irregular  rash  or  a  few 
vesicles  ;  there  is  the  same  disposition  to  bleeding,  and  the  same 
short  duration  and  fatal  termination  of  the  disease. 

The  hemorrhagic  form  of  small-pox  is  characterized  by  bleeding 
into  the  pustules  and  skin,  and  from  the  mouth,  nose,  bronchi, 
stomach,  intestines,  kidneys,  and  uterus.  It  has  already  been 
stated  that  this  disposition  to  bleeding  is  especially  marked  in  the 
malignant  cases.  It  is  also  occasionally  seen  in  the  ordinary 
cases  of  small-pox. 

Small-pox  modified  by  vaccination  (varioloid)  runs  a  milder  and 
shorter  course  than  does  the  unmodified  disease. 

The  period  of  invasion  may  be  shorter  or  longer,  more  or  less 
severe,  than  that  of  true  small-pox.  It  may  be  accompanied  by 
the  variolous  rashes.  With  the  appearance  of  the  eruption  the 
subsidence  of  the  constitutional  symptoms  is  nearly  complete. 
The  eruption  is  not  very  extensive,  the  pocks  are  small,  some  of 
the  vesicles  dry  up  without  suppurating,  the  pustules  are  not 
large  or  deep,  there  is  little  diffuse  inflammation  of  the  skin  or 
mucous  membranes  ;  desiccation  takes  place  on  from  the  fifth  to 
the  seventh  day  of  the  eruption. 

The  patients  regularly  recover,  and  some  are  not  sick  enough 
at  any  time  to  be  in  bed. 

Such  a  modified  small-pox,  however,  is  capable  of  giving  true 
small-pox  to  persons  unprotected  by  vaccination. 

The  convalescence  may  be  interfered  with  by  boils,  erysipelas, 
gangrene  of  the  skin,  laryngitis,  pleurisy,  pneumonia,  myelitis,  or 
septicaemia.  The  eye-sight  and  the  hearing  are  often  completely 
destroyed  by  the  pustules,  the  skin  is  permanently  deformed  by 
the  cicatrices  left  by  the  pustules. 

Mortality. — In  the  last  century,  in  many  countries,  from  seven 
to  twelve  per  cent,  of  all  the  deaths  were  due  to  small-pox.  Since 
the  introduction  of  vaccination  in  the  same  countries  small-pox 
is  a  comparatively  rare  disease. 

Malignant  and  hemorrhagic  small-pox  are  almost  certainly 
fatal ;  confluent  small-pox  is  very  dangerous  to  life  ;  from  dis- 
crete small-pox  the  percentage  of  recoveries  is  considerable  ; 
varioloid  is  very  seldom  fatal. 


SMALL-POX.  441 

Prophylaxis. — The  most  important'  duty  of  the  physician  as 
regards  small-pox  is  his  insistence  on  universal  vaccination  and 
revaccination.  Where  these  arethoroughly  carried  out  small-pox 
is  an  infrequent  disease  ;  where  they  are  neglected  serious  epi- 
demics attack  large  numbers  of  people. 

Treatment. — The  patients  are  to  be  kept  in  bed  with  the  ven- 
tilation, feeding,  and  nursing  appropriate  to  all  the  severe  infec- 
tious diseases. 

The  skin  is  to  be  covered  with  either  cold  or  warm  compresses 
of  a  weak  solution  of  carbolic  or  boric  acid,  and  frequently 
bathed  ;  or  frequent  immersions  in  warm  baths  for  several  hours 
every  day  may  be  practised. 

Vaccination. — The  great  mortality  from  small-pox  naturally  led 
to  attempts  to  protect  the  community  against  its  ravages.  It  was 
known  that  one  attack  of  the  disease  protected  against  subse- 
quent attacks,  and  so  the  trial  was  made  of  inoculation  of  matter 
from  the  pustules  of  small-pox.  It  was  found  that  the  protection 
afforded  by  inoculation  was  efficient,  but  that  its  practice  was  at- 
tended with  inconvenience  and  danger. 

Then  the  discovery  was  made  that  there  was  a  disease  of  cat- 
tle— cow-pox — which  resembles  small-pox,  and  that  the  virus 
from  cow-pox,  when  inoculated  in  human  beings,  gave  them  an 
immunity  from  small-pox.  From  the  time  of  this  discovery  vac- 
cination has  become  an  established  practice,  and  small-pox  has 
lost  its  terrors. 

When  vaccination  is  practised  in  an  unvaccinated  person,  on 
the  third  day  a  papule  is  formed ;  from  the  fifth  to  the  ninth  day 
a  vesicle  is  formed  on  the  papule  ;  on  the  eighth  day  the  vesicle 
and  papule  become  the  seat  of  suppurative  inflammation  ;  then 
the  inflammation  subsides,  and  from  the  twentieth  to  the  twenty- 
fifth  day  the  scab  falls  off  and  leaves  a  cicatrix  in  the  skin.  The 
evolution  of  the  pustule  is  accompanied  with  slight  constitutional 
disturbance. 

When  vaccination  is  practised  in  a  person  who  has  already 
been  vaccinated,  there  may  be  nothing  effected,  or  the  formation 
of  a  localized  inflammation  of  the  skin,  or  an  irregular  vaccine 
pustule.  The  ordinary  rule  is  to  vaccinate  all  infants,  to  re- 
vaccinate  once  in  about  seven  years,  or  oftener  in  case  of  ex- 
posure. 

The  protection  afforded  by  vaccination  varies  in  different  in- 
dividuals as  to  its  length  of  time  and  its  completeness.     It  may 


442  MEASLES. 

afford  absolute  immunity  against  small-pox,  or  it  may  only  insure 
a  mild  form  of  the  disease. 

The  only  dangers  attending  vaccination  are  erysipelas,  septi- 
caemia, and  syphilis.  All  of  these  can  be  guarded  against.  It  is 
customary  to  use  the  virus  taken  from  the  pustules  of  infants  or 
from  the  pustules  of  calves. 

Measles, 

Measles  is  a  very  contagious  disease.  Children  are  much 
more  susceptible  to  it  than  are  adults.  It  is  contagioias  both  in, 
the  period  of  invasion  and  in  that  of  eruption.  The  poison  of  the 
disease  is  given  off  from  the  surface  of  the  body,  it  floats  in  the 
air,  it  can  be  inoculated  with  the  blood,  it  lodges  in  clothing, 
bedding,  etc. 

Among  the  tenement-house  population,  in  asylums,  and  in 
armies  the  disease  is  often  of  severe  type  and  fatal  of  itself,  or  by 
its  complications.  When  introduced  for  the  first  time  in  savage 
tribes  it  is  exceedingly  fatal.  But  as  we  see  the  disease  under 
ordinary  conditions,  it  is  of  mild  type  and  very  seldom  fatal. 

Lesions. — The  characteristic  lesion  is  the  eruption  which  ap- 
pears on  the  skin  and  mucous  membranes. 

The  accessory  lesions  are  :  the  catarrhal  inflammations  of  the 
mucous  membranes  of  the  eyes,  nose,  throat,  larynx,  bronchi, 
stomach,  and  intestines  ;  the  croupous  laryngitis  ;  broncho-pneu- 
monia ;  simple,  suppurative,  or  tubercular  inflammation  of  the 
bronchial  or  cervical  lymphatic  glands  ;  suppurative  otitis  ;  acute 
degeneration  of  the  kidneys,  or  acute  exudative  nephritis. 

The  period  of  incubation  after  inoculation  with  the  blood  is 
seven  days  ;  after  ordinary  exposure,  from  ten  to  fourteen  days. 
During  the  period  of  incubation  there  may  be  a  little  fever  and 
disturbances  of  digestion. 

The  period  of  invasion  lasts  from  twelve  hours  to  six  days, 
usually  four  days. 

It  is  marked  by  chills,  sometimes  general  convulsions,  a  rapid 
rise  of  temperature,  headache,  vomiting,  and  diarrhoea.  At  the 
same  time  are  added  the  symptoms  of  the  catarrhal  inflammation 
of  one  or  more  of  the  mucous  membranes.  The  cases  vary  as  to 
the  number  and  severity  of  the  symptoms  during  the  period  of 
invasion. 

The  eruption   is  of  maculo-papular  form  tending  to  the  ere- 


MEASLES.  443 

scentic  shape.  The  'patches  are  of  light  or  dark  red  color,  of 
crescentic  or  irregular  shape,  scattered  or  confluent,  flat  or  papu- 
lar, sometimes  covered  with  vesicles,  sometimes  hemorrhagic. 
There  is  more  or  less  inflammation  of  the  skin  and  mucous  mem- 
branes between  the  blotches  of  the  eruption. 

The  eruption  appears  on  the  face,  neck,  trunk,  and  extremi- 
ties, and  on  the  mucous  membranes.  It  reaches  its  full  develop- 
ment in  from  two  to  four  days. 

After  from  ten  to  fourteen  days  there  is  a  fine  desquamation. 

The  fever  increases  as  the  eruption  is  developed,  and  is  usu- 
ally highest  as  the  eruption  becomes  complete. 

At  the  same  time  there  are  often  cerebral  symptoms  :  restless- 
ness, sleeplessness,  stupor,  delirium,  convulsions. 

During  the  period  of  eruption  the  patients  suffer  from  the 
symptoms  which  belong  to  the  inflammation  of  one  or  more  of  the 
mucous  membranes. 

The  conjunctivitis  is  attended  with  pain  and  intolerance  of 
light. 

The  pharyngitis  causes  pain  in  swallowing  and  cough. 

The  laryngitis  gives  pain,  laryngeal  cough,  laryngeal  voice, 
laryngeal  dyspnoea. 

With  the  bronchitis  we  find  the  ordinary  symptoms  and  phys- 
ical signs. 

The  gastritis  produces  pain  and  vomiting;  the  enteritis,  pain 
and  diarrhoea. 

The  eruption  and  the  fever  regularly  subside  in  from  two  to 
seven  days,  desquamation  follows,  and  convalescence  is  established 
from  the  tenth  to  the  fourteenth  day  after  the  beginning  of  the 
eruption. 

The  complications  of  most  consequence  are  :  broncho-pneumo- 
nia, gangrene  of  the  mouth  and  vulva,  suppurative  otitis,  adenitis, 
croupous  laryngitis,  and  nephritis. 

The  course  of  the  disease  is  regular,  or  very  rhild,  or  severe,  or 
malignant. 

The  malignant  cases  are  sometimes  called  "  black  measles." 
The  eruption  is  imperfectly  developed,  but  of  very  dark  color  ; 
the  prostration  is  extreme,  with  rapid  and  feeble  heart-action,  a 
cold  skin,  and  a  brown  and  dry  tongue  ;  there  are  marked  cere- 
bral symptoms  and  bleeding  from  the  mucous  membranes. 

Convalescence  may  be  interrupted  by  persistence  of  the  con- 
junctivitis,    pharyngitis,   otitis,    bronchitis,   broncho-pneumonia, 


444  SCARLATINA. 

gastritis,  or  tubercular  adenitis.  Or  the  patients  may  be  left  for 
a  long  time  feeble  and  ansemic. 

The  prognosis  in  ordinary  cases  is  very  good.  It  is  unfavora- 
ble in  children  under  two  years  of  age,  in  adults,  in  countries 
where  the  disease  prevails  for  the  first  time,  in  armies,  in  asylums, 
and  in  tenement-houses. 

Treatment  is  directed  to  the  fever,  the  cerebral  symptoms,  the 
skin,  the  conjunctivitis,  pharyngitis,  laryngitis,  bronchitis,  bron- 
cho-pneumonia, gastritis,  enteritis,  and  adenitis. 

Varicella. 

Chicken-pox. 

This  disease  is  almost  confined  to  children,  but  yet  is  occasion- 
ally seen  in  adults. 

It  is  fairly  contagious,  the  poison  is  given  off  from  the  surface 
of  the  sick  body. 

The  period  of  incubation  is  from  thirteen  to  seventeen  days. 

The  period  of  invasion  lasts  for  one  or  two  days.  The  pa- 
tients have  a  little  fever,  disturbances  of  digestion,  and  slight 
prostration. 

The  period  of  eruption  lasts  from  two  to  five  days.  First 
there  are  little  rounded  red  spots  in  the  skin,  then  papules,  and 
then  ve.sicles.  Many  of  the  vesicles  shrink  and  dry  up,  a  few  go 
on  to  form  pustules.  The  vesicles,  when  they  have  run  their 
course,  leave  the  skin  smooth  ;  the  pustules  leave  little  cicatricial 
depressions. 

The  eruption  appears  on  the  skin,  scalp,  mouth,  and  pharynx. 

The  disease  is  a  very  mild  one,  and  in  many  cases  there  can 
hardly  be  said  to  be  any  except  the  symptoms  eruption. 

Scarlatina. 

Lesions. — The  characteristic  lesion  is  the  eruption. 

The  accessory  lesions  are  frequent  and  important. 

The  pharynx  and  tonsils  are  the  seat  of  catarrhal,  croupous,  or 
gangrenous  inflammation. 

The  larynx  may  be  invaded  by  the  croupous  inflammation  of 
the  pharynx. 

The  Eustachian  tube  is  often  the  seat  of  catarrhal  inflamma- 
tion, the  middle  ear  of  suppurative  inflammation. 


SCARLATINA.  445 

The  cervical  lymphatic  glands  may  be  inflamed  and  swollen, 
or  they  may  suppurate.  The  kidneys  are  regularly  the  seat  of 
acute  degeneration,  of  acute  exudative  nephritis,  or  of  acute  dif- 
fuse nephritis. 

Etiology. — The  specific  micro-organism  of  scarlet  fever  has  not 
yet  been  determined.  The  poison  seems  to  exist  on  the  surface 
of  the  body  of  the  sick  person,  in  the  desquamated  epidermis,  and 
in  the  blood.  It  is  not  carried  to  any  distance  by  the  air,  but  it 
adheres  tenaciously  to  articles  of  clothing,  furniture,  toys,  etc., 
and  retains  its  vitality  for  a  long  time.  The  disease  is,  therefore, 
easily  carried  about  from  place  to  place.  It  can  be  inoculated 
with  the  blood,  but  we  do  not  know  certainly  the  ordinary  way 
in  which  the  disease  enters  the  body.  Although  the  poison  is  an 
active  one  and  exposure  is  regularly  followed  by  infection,  yet  a 
considerable  number  of  persons  enjoy  throughout  their  lives  en- 
tire immunity  from  the  disease,  no  matter  how  thoroughly  they 
are  exposed.  The  greatest  liability  to  the  disease  is  in  children 
between  the  ages  of  two  and  seven  years.  Adults  are  much  less 
susceptible  to  the  disease. 

The  puerperal  condition  and  surgical  operations  sometimes 
seem  to  render  persons  more  liable  to  the  disease  than  they  oth- 
erwise would  be.  One  attack  regularly,  but  not  always,  protects 
against  subsequent  attacks.  The  disease  varies  greatly  in  its  se- 
verity at  different  times  and  in  different  places. 

The  period  of  incubation  is  regularly  seven  days.  The  extreme 
limits  of  this  period  are  twenty-four  hours,  and  three  weeks. 
There  are  usually  no  symptoms  during  the  period  of  invasion, 
but  occasionally  there  is  a  little  sore  throat  and  the  patients  do 
not  feel  quite  well. 

The  period  of  invasion  lasts  for  from  twelve  to  forty-eight  hours, 
but  is  occasionally  prolonged  for  several  days.  It  is  marked  with 
a  sudden  rise  of  temperature,  accompanied  at  first  with  chills. 
The  height  reached  by  the  temperature  within  the  first  twenty- 
four  hours  is  in  proportion  to  the  severity  of  the  disease.  With 
the  fever  come  pains  in  the  head  and  back,  prostration,  restless- 
ness, delirium,  and  stupor. 

In  addition  to  the  fever  the  invasion  is  attended  with  general 
convulsions,  sore  throat,  or  vomiting. 

The  convulsions  are  especially  common  in  children,  there 
may  be  one  convulsion  or  several  within  the  first  twenty-four 
hours. 


446  SCARLATINA. 

The  vomiting  belongs  to  the  first  hours  of  the  invasion,  either 
a  single  sudden  attack,  or  repeated  vomiting  and  retching. 

The  sore  throat  is  a  general  catarrhal  inflammation  of  the 
pharynx  and  tonsils.  It  is  attended  with  a  good  deal  of  conges-  . 
tion,  so  that  the  throat  looks  more  red  and  angry  than  is  the 
case  with  a  simple  pharyngitis.  With  the  sore  throat  there  is 
also  a  swelling  of  the  papillae  of  the  tongue,  the  strawberry 
tongue. 

The  fever  increases,  the  sore  throat,  the  cerebral  symptoms, 
and  the  prostration  continue  while  the  eruption  is  developing. 

The  eruption  is  in  the  form  of  minute  red  points.  These  are 
numerous  and  close  together,  so  as  to  form  an  extensive  diffuse 
redness  ;  or  they  are  aggregated  in  irregular  patches ;  or  they 
are  separated  and  scattered.  The  eruption  first  appears  on  the 
neck  and  shoulders,  and  then  extends  to  the  trunk,  arms,  and  legs. 
It  reaches  its  full  development  in  from  one  to  four  days,  and 
then  the  skin  is  nearly  uniformly  red,  swollen,  and  tense.  The 
regular  and  fully  developed  eruption  is  very  characteristic 
and  not  likely  to  be  mistaken  for  that  of  any  other  disease.  But 
irregular  forms  are  of  common  occurrence,  and  are  often  very 
puzzling.  The  eruption  may  be  confined  to  the  trunk,  the  limbs, 
or  the  face  ;  it  may  never  reach  its  full  development,  but  remain 
in  the  form  of  scattered  patches  or  points ;  its  entire  duration 
may  be  confined  to  a  few  hours  ;  there  are  cases  in  which  no  rash 
is  seen  at  any  time. 

The  whole  duration  of  a  regular  eruption  is  from  three  to 
ten  days.  As  the  eruption  subsides  the  dead  epidermis  begins  to 
come  away  in  flakes  and  large  patches,  and  this  desquamation 
continues  until  the  end  of  the  third  week,  or  even  longer. 

Course  of  the  Disease. — i.  The  regular  cases. 

The  invasion  of  the  disease  is  sudden,  with  chills,  fever,  head- 
ache, restlessness,  delirium,  and,  in  addition,  vomiting,  convul- 
sions, or  sore  throat.  After  from  twelve  to  thirty-six  hours,  while 
the  temperature  continues  to  rise  and  the  patients  begin  to  look 
more  sick,  the  eruption  appears.  It  is  seen  first  on  the  neck  and 
chest,  then  rapidly  extends  over  most  of  the  body,  and  the  skin  be- 
comes uniformly  red  and  swollen.  By  the  fourth  day  the  inflamma- 
tion of  the  skin  reaches  its  maximum,  and  after  that  day  subsides. 
In  from  five  to  ten  days  the  eruption  has  entirely  disappeared. 
About  the  seventh  day  the  pharyngitis  subsides,  the  temperature 
falls,  all  the  constitutional  symptoms  disappear.     By  the  end  of 


SCARLATINA.  447 

the  second  week  the  patients  seem  to  be  well.  By  the  end  of  the 
third  week  desquamation  is  complete  and  the  disease  has  run  its 
course. 

2.  The  disease  runs  its  regular  course,  but  the  fever,  instead 
of  subsiding  on  the  seventh  day,  continues  for  one  or  two  weeks. 

3.  The  eruption  is  irregular  as  to  its  appearance,  situation,  or 
duration,  while  the  other  symptoms  are  regular. 

4.  There  are  very  mild  cases  with  but  trivial  constitutional 
symptoms  and  a  scanty  and  short  eruption,  but  with  the  charac- 
teristic desquamation  and  the  liability  to  complications. 

5.  There  are  cases  in  which  the  only  symptoms  are  fever  and 
sore  throat. 

6.  There  are  severe  and  prolonged  cases.  The  eruption  is 
either  scanty  or  abundant,  but  the  constitutional  symptoms  are 
marked,  especially  the  fever  and  cerebral  symptoms.  The  pa- 
tients  are  seriously  ill  for  two  or  three  weeks,  and  may  die  from 
the  scarlatina  alone  without  any  complication. 

7.  There  are  malignant  cases.  The  patients  look  from  the 
first  as  if  they  were  overwhelmed  with  the  poison  of  the  disease. 
The  temperature  is  excessively  high  or  below  the  normal.  The 
cerebral  symptoms  are  marked  and  the  heart's  action  rapid  and 
feeble.  Vomiting,  diarrhoea,  dyspnoea,  and  bleeding  from  the 
mucous  membrane  are  often  present.  The  eruption  is  irregular 
and  dark-colored.  The  patients  die  in  from  eight  hours  to  two 
days. 

Dr.  H.  Noble  Joynt  [Lancet,  189 1)  gives  the  following  descrip- 
tion from  the  personal  observation  of  one  hundred  malignant 
cases  : 

Although  the  general  course  is  similar  in  all  instances,  yet 
clinically  three  well-marked  varieties  may  be  noted,  as  regards 
the  character  of  the  rash,  the  extent  of  the  throat  inflammation, 
the  prominence  of  the  nervous  symptoms,  the  duration  of  the 
fever,  and  the  prognosis. 

In  the  first  or  asthenic  variety  the  following  characteristics 
appear :  The  rash  is  badly  mai'ked,  being  either  wholly  sup- 
pressed or  scanty,  distributed  in  irregular  dark  blotches  on  the 
limbs  and  gluteal  region  ;  or,  again,  it  may  consist  of  a  general 
eruption  of  scattered  dark  maculae  resembling  typhus  fever. 
Purpuric  blotches  and  spots  are  frequent,  as  well  as  petechiae  on 
the  arms,  chest,  sides,  back,  and  abdomen,  but  best  seen  over  the 
legs  and  backs  of  the  feet.  The  lower  extremities  are  cold  and  pre- 


448  SCARLATINA. 

sent  a  livid  appearance,  Tlie  face  is  pale,  pinched,  and  cyanosed, 
the  lips  and  cheeks  bluish,  and  the  circumoral  pallor  pronounced. 
The  eyes  become  sunken  and  surrounded  by  dark  rings  ;  the 
conjunctiva  is  sometimes  injected,  but  usually  anaemic  ;  the  cor- 
nea dull  and  covered  with  a  mucous  film  ;  the  eyelids  fail  to 
close.  At  first  the  tongue  is  thickly  furred,  but  becomes  dry  and 
coated  with  a  dirty-brown  secretion  ;  sordes  gather  on  the  lips 
and  teeth.  The  fauces  are  somewhat  swollen,  foul,  dryish,  of 
a  dark  purplish-red  color,  and  the  tonsils  slightly  enlarged.  Un- 
less kept  frequently  syringed  all  the  structures  of  the  mouth  be- 
come coated  with  a  foul  viscid  mucus,  which  clings  to  the  palate 
and  tongue,  and  effectually  hinders  inspection  of  the  fauces.  If 
the  throat  inflammation  becomes  more  intense,  the  tonsils  en- 
large, superficially  ulcerate,  and  a  fetid,  purulent  discharge 
oozes  from  the  nostrils.  But  in  this  group  ulceration  is  always 
slight  and  secondary,  faucial  swelling  and  dark  congestion  be- 
ing the  conspicuous  features.  Vomiting  of  a  green,  bilious  nat- 
ure is  very  frequent,  the  irritability  of  the  stomach  is  extreme, 
and  nothing  swallowed  is  retained.  To  add  to  the  difficulty  of 
feeding  the  patient,  diarrhoea  accompanies  the  vomiting  and 
renders  the  rectal  alimentation  wellnigh  impossible.  The  tem- 
perature is  always  high,  ranging  from  102°  F.  to  106°  F.  The 
pulse  is  very  rapid,  reaching  200  beats  per  minute  ;  it  is  soft,  ir- 
regular^,  compressible,  and  so  feeble  as  to  be  imperceptible  at  the 
wrist.  The  heart  is  excited,  quickly  becomes  vyeak,  the  sounds 
barely  distinguishable,  and  in  young  children  uncountable. 
Respiration  is  quickened,  shallow,  and  sighing,  and  toward  the 
end  may  exhibit  the  Cheyne-Stokes  rhythm.  The  nervous 
symptoms  are  among  the  most  pronounced.  Delirium,  worse  at 
night,  is  constant,  often  continuing  throughout  the  whole  illness. 
At  first  the  patient  may  be  violent,  getting  out  of  bed,  etc.  ; 
more  usually,  however,  the  delirium  is  of  a  low  muttering  type, 
gradually  passing  into  coma.  The  child  is  very  restless,  rolling 
from  side  to  side,  tossing  his  arms  about,  boring  his  head  into 
the  pillow,  moaning,  and  grinding  his  teeth.  Muscular  tremors 
of  the  tongue,  face,  and  hands,  and  twitching  of  single  groups  of 
muscles  may  be  noticed  ;  but,  above  all,  what  strikes  the  ob- 
server is  the  utter  prostration.  Toward  the  end  the  patient  sinks 
into  a  comatose  condition.  If  he  lives  four  or  five  days,  a  typhoid 
state,  with  dry  tongue,  cold  extremities,  dull  eyes,  foul  mouth, 
sordes,  pinched,  pallid    face,  involuntary    evacuations,  hiccough. 


SCARLATINA.  449 

etc.,  develop.  In  young  adults  the  mind  may  continue  clear 
almost  to  the  last.  Syncope  is  a  common  cause  of  death  ;  con- 
vulsions in  a  few  instances  bring  on  the  fatal  ending.  Death  oc- 
curs as  a  rule  within  four  days  ;  in  young,  weakly,  and  rickety 
children  in  a  shorter  period.  One  boy,  aged  two,  whose  sister 
also  died  of  malignant  symptoms,  succumbed  in  thirty  hours  ;  a 
girl,  aged  three,  in  thirty-six  hours;  another  boy,  aged  fourteen, 
in  about  fifty-six  hours  ;  and  sixteen  others  died  in  seventy-two 
hours  and  under.  As  a  rule,  the  older  and  stronger  the  subject, 
the  better  the  fight  for  life  is.  Thus  a  man,  aged  twenty-eight, 
lingered  for  six  days  ;  another,  aged  eighteen,  lived  for  five  ; 
and  a  third  boy,  aged  seventeen,  had  sufficient  vitality  to  pull 
through,  but  when  apparently  convalescing  well,  fell  a  victim  to 
an  unexpected  attack  of  double  basal  pneumonia  during  the  third 
week. 

In  the  second  or  anginal  variety  the  character  and  course  of 
the  fever  are  much  the  same  as   that  already  described,  but  the 
throat  symptoms  are  more  conspicuous.     The  tonsils  are  more 
swollen,  ulceration  is  always  present,  may  spread  to  the  pharynx 
and  nasal  passages,  and  set  up  a  fetid,  purulent  rhinorrhoea.     A 
diphtheritic  membrane  often  coats  the  tonsils  and  meatus  of  the 
nose.     The  mouth  is  very  foul,  and  the  submaxillary  glands   en- 
large  to  a  moderate  degree.     The   rash  is  scanty,  dark,  patchy, 
petechial,  often   of  a  livid  hue,  especially  on   the  extremities  ; 
rarely  is  the  eruption  general,  and   then   it  is   measly  and  dark. 
Delirium  and  vomiting  are  not  so  marked,  but   the  temperature 
is  as  high,  and  the  pulse  as  rapid  and  feeble,  as  in  the  asthenic 
variety.     Slight    laryngitis    was   noted    in    two  instances  on  the 
second  and  third  days,  respectively.     This  group  presents  a  like- 
ness to  the  acuter  course  of  anginal  scarlatina,  and  indeed  is  the 
connecting  link   between  the  two.     But  it  differs  from  the  true 
anginal  fever  in   that  there  are  no  secondary  inflammatory  or 
plastic  lesions,  such  as  adenitis,  cellulitis,  otitis  media,  or  other 
extensive  ulcerative  changes,  in  the  pharynx  and  nasal  passages  ; 
moreover,  death  is  due  to  the  toxic  effects  of  the  scarlatinal  poison 
on  the  nerve-centres,  and  not  to  exhaustion  from   suppuration, 
septic  infection,  or  inflammatory  obstruction  of  the  vital  organs. 
It  may  be  laid  down  as  a  general  rule  that  in  scarlatinal  angina 
death  is  caused  by  a  complication.     In  this  type  children  under 
five,  with  short  necks  and  strumous  or  rickety  habit,  are  the  chief 
sufferers,  and  death  is  frequently  the  result  of  syncope. 


450  SCARLATINA. 

The  third  or  congestive  variety  presents  some  remarkable 
differences  from  the  foregoing.  The  eruption  is  very  character- 
istic. Tiie  whole  body  is  covered  with  a  dark,  often  livid,  in- 
tense diffuse  or  punctiform  rash,  aptly  likened  to  the  color  of  a 
boiled  lobster.  Petechiae,  small  hemorrhages,  and  darker  macu- 
lae are  common.  The  face  is  flushed,  the  rash  well  developed 
over  the  scalp,  on  the  forehead,  and  sides  of  the  face,  and  the 
circumoral  pallor  is  replaced  by  a  crimson  hue.  The  eyes  are 
considerably  congested,  and  hemorrhages  may  take  place  into 
the  orbital  conjunctivae.  A  copious  miliary  eruption  on  the 
trunk  is  sometimes  seen.  About  the  fourth  day  the  skin  becomes 
dry,  often  leathery  or  parchment-like  in  texture,  and  of  a  dark 
red-brown  color.  At  the  same  time  desquamation  appears  on 
the  forehead  and  cheeks,  round  the  nose  and  mouth,  on  the  chin, 
neck,  shoulders,  and  inside  of  thighs.  The  skin  peels  off  in 
sheets,  and  with  care  casts  of  the  fingers  and  toes  may  be  ob- 
tained. In  cases  that  recover  the  skin  may  be  completely  cast 
off  twice  or  thrice  in  the  first  fortnight.  The  secondary  skin, 
and  even  the  third,  has  the  intense  scarlet  hue  of  the  primary 
rash.  The  throat  is  dry,  but  little  swollen  ;  the  tonsils  are  seldom 
enlarged,  but  the  mucous  membrane  has  a  peculiar  dark  red- 
brown  hue,  well  likened  by  Dr.  W.  H.  Line*  "to  the  appear- 
ance and  glazed  lustre  of  well-polished  Spanish  mahogany  ;"  ul- 
ceration is  uncommon,  and  superficial  when  present.  The  tongue 
is  pointed  and  dark,  raw-looking,  stripped  by  the  third  day,  and 
the  papillae  stand  out  prominently.  Active  delirium  is  present  in 
nearly  every  case,  and  it  is  often  difficult  to  keep  the  patient  in 
bed.  Vomiting  is  infrequent,  but  before  death  the  stomach  mav 
reject  everything.  The  temperature  ranges  from  102°  to  106° 
F.  and  higher  ;  the  pulse  is  rapid,  soft,  and  compressible.  As 
the  fever  advances  nervous  tremors  develop,  prostration  becomes 
very  marked,  the  eyes  become  sunken,  the  face  pinched  and 
cyanosed,  the  pulse  thready,  hypostatic  congestion  of  the  lungs 
sets  in,  the  motions  are  passed  involuntarily,  and  death  ensues 
from  the  fourth  to  the  eighth  day.  Fortunately,  however,  this 
variety  is  not  so  fatal  as  the  other  two  ;  three-fifths  of  our  cases 
recovered.  This  may,  perhaps,  be  accounted  for  by  the  fact  that 
the  patients  were  older  and  stronger  than  in  the  former  classes. 
It  is  more  common  in  patients  over  seven  years  of  age.  Thus,  in 
25  cases,  7  occurred  in  patients   under  five,  of  whom  5   died  ;  8 

*  Birmingham  Medical  Review,  March,  1885. 


SCARLATINA,  45 1 

between  six  and  ten  ;  7  between   eleven  and  fifteen  ;  and   3   over 
sixteen.     As  regards  sex,  14  were  males  and  11  females. 

8.  A  person  suffering  from  scarlet  fever  may,  at  any  time  in 
the  course  of  the  disease,  have  an  attack  of  true  diphtheria. 

9.  Persons  suffering  from  scarlet  fever,  instead  of  having  the 
ordinary  catarrhal  inflammation  of  the  pharynx  and  tonsils,  may 
have  a  croupous  inflammation  \vith  the  growtla  of  streptococci. 
These  patients  are  said  to  liave  scarlatinal  diphtheria,  but  the  in- 
flammation is  accompanied  by  the  growth  of  streptococci,  not  by 
the  growth  of  the  Klebs-Loffler  bacillus.  Such  a  croupous  in- 
flammation may  be  of  mild  or  severe  type. 

{a)  On  the  first,  second,  or  third  day  of  the  scarlet  fever,  one 
or  both  tonsils  become  swollen  and  coated  with  small  patches  of 
false  membrane  which  gradually  increase  in  size,  and  the  lym- 
phatic glands  of  the  neck  become  somewhat  swollen.  The  in- 
flammation continues  for  about  four  days,  then  subsides,  and  by 
the  end  of  a  week  has  disappeared.  While  the  inflammation  of 
the  throat  is  running  its  course,  the  symptoms  of  the  scarlet 
fever  continue  and  are  not  changed  by  the  sore  tliroat,  nor  is  the 
patient  in  any  danger  from   it. 

(^)  The  mucous  membrane  of  the  tonsils  and  pharynx  is  at 
first  intensely  congested  and  swollen.  About  the  third  day  of 
the  scarlet  fever  the  temperature  runs  up  and  the  mucous  mem- 
brane of  the  throat  and  nose  is  much  more  swollen,  covered  with 
tenacious  mucus,  and  a  foul-smelling  fluid  exudes  from  the 
nose.  The  lymphatic  glands  in  the  neck  are  swollen,  and  soon 
the  connective  tissue  of  the  neck  is  swollen,  hard,  and  infiltrated, 
and  this  swelling  increases,  pushes  the  head  backward,  and  ex- 
tends around  the  neck.  The  patients  now  look  as  if  they  were 
suffering  from  septic  poisoning,  with  high  temperatures  and  a 
feeble  heart.  Next  comes  the  necrosis  of  portions  of  the  inflamed 
mucous  membrane,  of  the  lymphatic  glands,  and  of  the  infiltrated 
tissues  of  the  neck,  and  soon  after  this  the  death  of  the  patient. 
The  whole  picture  is  that  of  a  gangrenous  inflammation  with 
septic  poisoning. 

(c)  The  scarlet  fever  begins  without  any  alarming  symptoms, 
the  tonsils  and  pharynx  are  moderately  inflamed,  the  patients 
seem  to  be  doing  well  until  the  latter  part  of  the  first  week  of  the 
disease.  Then,  instead  of  beginning  to  improve,  the  patients 
seem  to  stand  still  or  to  look  a  little  worse.  The  throat  is  still 
only  moderately  inflamed,  but  the  lymphatic  glands  in  the  neck 


452  SCARLATINA. 

are  swollen.  After  this  the  mucous  membrane  of  the  throat  be- 
comes a  little  more  swollen,  with  more  or  less  false  membrane,  a 
yellow  or  bloody  fluid  exudes  from  the  nose,  there  are  unhealthy 
fissures  at  the  edge  of  the  nose  and  the  corners  of  the  mouth.  It 
is  not,  however,  until  the  second  week  of  the  scarlet  fever  that 
the  condition  of  these  patients  becomes  threatening.  The  lym- 
phatic glands  in  the  neck  are  now  much  enlarged,  with  infiltra- 
tion of  the  adjacent  connective  tissue  and  skin.  There  is  a  dis- 
charge of  foul-smelling  saliva  from  the  mouth,  ulcers  are  formed 
in  the  pharynx  and  tonsils  with  gangrenous  edges,  and  brown, 
gangrenous  patches  can  be  seen  in  the  mucous  membrane.  The 
lymphatic  glands  and  the  skin  of  the  neck  also  become  gangre- 
nous, the  large  veins  and  arteries  in  the  neck  may  be  eroded,  or 
septic  thrombi  are  formed  in  the  veins.  The  patients  may  have 
diarrhoea,  or  purulent  inflammation  of  the  joints,  or  purulent  in- 
flammation of  the  serous  membranes.  The  temperature  con- 
tinues high,  the  patients  steadily  lose  flesh  and  strength,  and  die 
after  from  three  to  five  weeks. 

10.  Suppurative  inflammation  of  the  middle  ear  may  be  de- 
veloped at  any  time  in  the  course  of  scarlet  fever.  It  is  attended 
with  a  rise  of  temperature,  pain,  restlessness,  sometimes  stupor 
and  delirium.  These  symptoms  may  be  so  marked  as  to  simulate 
an  acute  meningitis.  They  continue  until  the  membrana  tympani 
is  ruptured  and  the  pus  escapes. 

11.  Inflammation  of  the  lymphatic  glands  of  the  neck  belongs 
to  the  middle  or  end  of  the  second  week.  The  glands  are  simply 
swollen  or  they  suppurate.  Such  an  adenitis  is  accompanied 
with  fever  and  sometimes  lasts  for  a  long  time. 

12.  Acute  pericarditis  or  endocarditis  may  be  developed  at 
any  time  in  the  disease. 

13.  Inflammation  of  the  joints  or  of  the  muscles  may  occur 
as  the  eruption  is  subsiding.  The  joints  most  frequently  affected 
are  those  of  the  hands  and  feet  ;  the  muscles,  those  of  the  neck. 
With  the  synovitis  or  myositis  there  is  more  or  less  fever. 

14.  The  poison  of  scarlet  fever  is  capable  of  producing  three 
morbid  changes  in  the  kidneys  : 

{a)  Acute  degeneration  belongs  to  the  first  and  second  weeks 
of  the  disease.  It  is  of  mild  type.  The  quantity  of  the  urine  is 
but  slightly  diminished,  its  specific  gravity  is  unchanged,  it  con- 
tains a  little  albumin  and  a  few  casts.  It  is  not  accompanied 
with  any  constitutional  symptoms,  and    the    kidneys    return  to 


SCARLATINA.  453 

their  normal  condition  after  the  patients  have  recovered  from 
their  scarlet  fever. 

{b)  Acute  exudative  nephritis  belongs  to  the  second  and  third 
weeks  of  scarlet  fever.  The  urine  is  scanty  or  suppressed,  its 
specific  gravity  is  unchanged,  it  contains  large  quantities  of  albu- 
min, numerous  casts,  and  blood.  The  temperature  rises  some- 
times as  high  as  105°  ;  there  are  prostration,  headache,  nausea, 
vomiting,  anaemia,  and  dropsy.  In  some  of  the  patients  there  is 
added  contraction  of  the  arteries,  with  disturbance  of  the  heart's 
action  and  general  convulsions,  delirium,  or  stupor.  Most  of 
these  cases  of  nephritis  last  about  four  weeks,  and  terminate  in 
recovery,     A  smaller  number  prove  fatal. 

[c)  Acute  diffuse  nephritis  belongs  to  the  third  week  and  the 
period  of  convalescence.  It  follows  either  an  acute  or  subacute 
type.  The  acute  cases  in  their  early  stages  resemble  exudative 
nephritis.  In  the  subacute  cases  the  symptoms  are  developed 
gradually.  The  urine  is  somewhat  diminished  in  quantity,  con- 
tains much  albumin  and  casts,  but  no  blood.  There  is  no  fever. 
The  anaemia  and  dropsy  are  developed  gradually.  In  all  cases 
of  diffuse  nephritis  the  kidney  disease  is  apt  to  persist  and  to  go 
on,  quickly,  slowly,  or  with  intermissions,  up  to  the  patient's 
death. 

15.  In  the  third  week  of  scarlet  fever  there  may  be  developed 
a  general  subcutaneous  oedema  without  disease  of  the  kidneys. 
This  seems  to  depend  in  some  way  on  the  inflammation  qf  the 
skin. 

16.  Meningitis,  pleurisy,  broncho-pneumonia,  and  peritonitis 
are  comparatively  rare  complications. 

Convalescence. — Some  of  the  patients  are  left,  after  the  scarlet 
fever,  for  a  long  time  feeble  and  anaemic,  or  mentally  feeble. 

Chronic  nephritis,  protracted  adenitis,  or  protracted  endo- 
carditis may  seriously  interfere  with  convalescence. 

Treatment. — The  patients  must  be  kept  in  one  room,  or  one 
set  of  rooms,  for  three  weeks  from  the  beginning  of  the  eruption. 
They  must  be  kept  in  bed  while  the  fever  and  constitutional 
symptoms  continue.  They  are  not  to  be  allowed  animal  food 
until  the  completion  of  the  three  weeks.  The  rooms  are  to  be 
kept  well  ventilated,  the  patient's  skin  must  be  washed  every  day 
with  warm  water  and  soap. 

Excessively  high  temperatures  may  be  reduced  by  antipyrin, 
antifebrin,  or  phenacetine. 


454  GERMAN   MEASLES. 

The  sleeplessness,  restlessness,  and  cerebral  symptoms  may 
be  alleviated  by  opium,  the  bromides,  or  sulphonal. 

Special  treatment  may  be  needed  for  the  pharyngitis,  otitis, 
adenitis,  or  nephritis. 

German  Measles. 

Synonyjns. — Rotheln  ;  Roseola  ;  Rubella  ;  Rubeola. 

History. — During  the  eighteenth  and  nineteenth  centuries,  in 
different  countries,  there  have  been  numerous  epidemics  of  erup- 
tive diseases  which  resembled  either  measles  or  scarlet  fever,  and 
yet  seemed  in  some  ways  distinct  from  these  diseases.  So  two 
opinions  have  been  held  on  the  subject.  Some  physicians  have 
believed  that  there  is  an  exanthematous  disease  entirely  distinct 
from  measles  and  scarlet  fever  ;  others  that  the  apparent  ex- 
amples of  such  a  disease  are  only  irregular  forms  of  the  two  well- 
known  exanthemata.  At  the  present  time  the  prevailing  opinion 
seems  to  be  that  there  is  a  distinct  exanthematous  disease  apart 
from  measles  and  scarlet  fever  which  is  not  a  modification  or  a 
variety  of  either  of  these  diseases. 

Etiology. — The  disease  seems  to  be  communicated  from  person 
to  person,  but  the  poison  is  not  very  active  nor  very  long  lived, 
so  that  of  all  the  persons  exposed  a  considerable  number  escape. 
It  occurs  for  the  most  part  in  epidemics,  and  may  disappear  alto- 
gether between  the  epidemics.-  Children  are  more  liable  to  the 
disease  than,  are  adults.  The  epidemics  of  German  measles  have 
often  occurred  at  the  same  time  with  an  increased  prevalence  of 
true  measles,  or  of  scarlet  fever,  and  it  has  been  found  that  Ger- 
man measles  does  not  protect  against  either  measles  or  scarlet 
fever,  but  does  protect  against  itself. 

The  period  of  incubation  seems  to  vary  in  different  epidemics  ; 
the  most  frequent  length  of  time  is  from  fourteen  to  twenty-one 
days,  but  an  incubation  of  only  six  days  is  not  uncommon.  There 
are  no  symptoms  during  this  period. 

A  period  of  invasion  is  very  often  entirely  absent.  When  it 
does  occur  it  does  not  usually  last  more  than  twenty-four  hours, 
but  it  may  be  prolonged  for  two,  three,  four,  or  even  five  days. 
The  symptoms  which  belong  to  this  period  are  :  a  febrile  move- 
ment, headache,  rarely  general  convulsions,  nausea,  vomiting, 
conjunctivitis,  pharyngitis,  laryngitis,  and  swelling  of  the  glands 
of  the  neck.  As  compared  with  measles  or  scarlet  fever,  the 
symptoms  of  the  invasion  of  this  disease  are  insignificant. 


GERMAN   MEASLES.  455 

Period  of  Eriiptioti. — Very  often  the  patient  is  ignorant  of  his 
attaclc  until  he  discovers  the  eruption,  and  this  discovery  is  often 
made  early  in  the  morning.  The  rash  appears  first  on  the  fore- 
head and  temples,  rapidly  extends  over  the  face,  neck,  trunk,  and 
lastly  over  the  extremities.  It  is  in  the  form  of  minute  pinkish 
points,  which  are  aggregated  into  separate  blotches  like  those  of 
measles,  or  into  a  diffuse  rash  like  that  of  scarlet  fever. 

In  some  cases  the  maculae  are  changed  to  papulae,  and  on  the 
surfaces  of  these  are  small  vesicles  or  pustules.  The  eruption  is 
regularly  the  prominent  symptom,  altogether  out  of  proportion 
to  the  constitutional  symptoms.  It  appears  on  the  face,  body, 
and  extremities,  and  lasts  for  from  one  to  seven  days.  It  often 
fades  in  one  place  before  it  appears  in  another.  It  is  not  usually 
followed  by  desquamation. 

During  the  period  of  eruption  there  may  be  a  little  fever,  a 
coated  tongue,  conjunctivitis,  pharyngitis,  swelling  of  the  lym- 
phatic glands  in  the  back  of  the  neck,  synovitis  of  the  smaller 
joints,  inflammation  of  the  muscles  of  the  neck,  bronchitis,  or 
broncho-pneumonia. 

The  disease  is  not  a  severe  one,  and  requires  no  treatment  ex- 
cept for  the  alleviation  of  symptoms. 


THE   MALARIAL   DISEASES. 


This  name  is  given  to  a  group  of  disorders  which  are  pro- 
duced by  a  special  poison  originating  in  the  earth  and  taken  into 
the  bodies  of  human  beings.  These  disorders  are  called  Inter- 
mittent Fever,  Remittent  Fever,  and  Malarial  Cachexia. 

The  malarial  diseases  exist  in  their  most  severe  forms  in 
Africa,  Asia,  India,  China,  the  West  India  Islands,  South 
America,  and  Central  America.  In  these  countries  remittent 
fever  and  malarial  cachexia  prevail  constantly,  are  of  severe  type, 
and  are  often  fatal. 

These  diseases  exist  in  a  well-marked  form  in  the  southern 
and  western  portions  of  the  United  States,  in  parts  of  Russia, 
Greece,  Hungary,  Italy,  Germany,  France,  the  Netherlands, 
Spain,  England,  and  Scotland.  In  these  countries  intermittent 
fever,  remittent  fever,  and  malarial  cachexia  prevail  nearly  con- 
stantly, occur  in  epidemics,  and  exhibit  varying  degrees  of  sever- 
ity. The  disease  will  from  time  to  time  invade  fresh  districts,  or 
will  assume  the  mild  form,  or  may  disappear  altogether  from  re- 
gions where  it  has  already  prevailed. 

The  mild  form  of  malarial  disease  is  seen  in  the  middle  and 
eastern  portions  of  the  United  States  and  in  parts  of  Europe. 
Intermittent  fever  and  malarial  cachexia  in  their  milder  forms 
come  and  go  in  different  localities,  sometimes  very  prevalent, 
sometimes  rare,  sometimes  disappearing  altogether. 

In  the  countries  where  the  most  severe  form  of  malaria  exists, 
the  rainy  season  is  the  worst. 

In  those  countries  where  its  well-marked  form  prevails,  it  is 
most  common  in  spring  and  autumn. 

In  those  places  where  the  mild  form  of  the  disease  belongs,  it 
is  most  common  in  spring  and  autumn. 

The  ordinary  rules  are  :  That  the  frequency  of  the  disease 
diminishes  with  the  elevation  above  the  sea-level  ;  that  marshy 
soils  are  the  worst  and  sandy  soils  the  best  ;  that  the"  draining  of 
marshes  and  ponds,  the  cultivation  of  virgin  soil,  and  the  aban- 


THE   MALARIAL   DISEASES.  457 

donment  for  a  long  time  of  cultivated  soil,  are  followed  by  an  in- 
creased prevalence  of  the  disease. 

Where  the  mild  forms  of  the  disease  exist  it  is  difficult  to  lay 
down  any  rules  as  to  the  conditions  which  favor  the  appearance 
and  disappearance  of  the  disease. 

There  seems  to  be  a  well-marked  difference  in  different  indi- 
viduals as  to  their  susceptibility  to  the  disease. 

Lesions. — Tlie  poison  of  the  malarial  diseases  is  a  form  of  pro- 
tozoa, called  the  "  plasmodium  malarise."  The  organism  seems 
to  originate,  live,  and  grow  in  the  earth  and  water,  and  to  be  capa- 
ble of  floating  in  the  air.  It  is  apparently  taken  into  the  human 
body  through  the  lungs.  After  they  have  been  taken  into  the 
human  body  the  micro-organisms  find  their  way  into  the  red 
blood-cells,  they  increase  in  size,  they  multiply,  they  destroy  the 
red  blood-cells  with  liberation  of  their  pigment. 

In  its  earliest  form  the  plasmodium  is  in  the  form  of  very 
small,  pale,  crescentic,  or  irregular  bodies  contained  within  the 
red  blood-cells.  These  bodies  increase  in  size,  the  red  blood-cells 
are  destroyed,  their  pigment  is  set  free,  and  is  found  in  blackish 
granules  in  the  plasmodium,  in  the  white  blood-cells,  and  in  free 
masses  and  granules. 

The  pigment  is  especially  abundant  in  the  blood  of  the  liver 
and  spleen.  Some  of  the  organisms  assume  a  peculiar  shape,  as 
of  a  body  with  long  threads  projecting  from  it.  After  a  time 
there  is  a  segmentation  of  the  organisms  and  the  formation  of  a 
new  crop,  which  again  invade  the  red  blood-cells. 

The  spleen  is  very  often  hypertrophied.  The  red  blood-cells 
are  diminished  in  number.  The  pigment  due  to  the  destruction 
of  the  red  blood-cells  may  be  found  within  the  blood-vessels  in 
all  parts  of  the  body,  but  in  the  liver  and  spleen  the  quantity  is 
so  great  that  these  organs  are  fairly  black. 

Intermittent  Fever. 

The  period  of  incubation  varies  from  a  few  days  to  several 
months. 

When  the  disease  has  once  been  acquired,  the  paroxysms  may 
return  at  intervals,  without  fresh  exposure,  for  many  years. 
Change  of  climate  and  accidental  circumstances  may  be  the  ex- 
citing causes  of  paroxysms. 

The  symptoms  occur  in   paroxysms,   which  are  repeated  at 


458  THE   MALARIAL   DISEASES. 

regular  intervals,  every  day,  every  other  day,  or  at  longer  in- 
tervals. The  paroxysms  are  repeated  at  the  same  hour  on 
the  successive  days,  or  the  time  may  be  anticipated  or  post- 
poned 

Each  complete  paroxysm  has  three  stages  :  the  cold,  the  hot, 
and  the  sweating. 

The  cold  stage  is  attended  with  chills,  a  cold  skin,  a  rapid 
pulse,  and  irritability  of  the  stomach.  It  lasts  for  frorn  half  an 
hour  to  two  hours. 

The  hot  stage  is  attended  with  a  rapid  rise  of  temperature, 
the  skin  is  hot  and  dry,  the  pulse  full  and  rapid  ;  vomiting,  head- 
ache, and  pain  in  the  back  are  present.  It  lasts  for  from  two  to 
twelve  hours. 

In  the  stage  of  sweating,  the  temperature  falls,  all  the  symp- 
toms subside,  and  there  is  profuse  perspiration. 

Irregular  paroxysms  may  occur,  in  which  either  the  cold  Or 
the  sweating  stage  are  absent. 

When  the  paroxysms  are  repeated  for  a  long  time,  the  spleen 
is  hypertrophied,  the  number  of  red  blood-cells  is  diminished, 
and  the  general  health  is  impaired. 

Instead  of  a  regular  paroxysm,  there  may  be  a  chill,  a  rise  of 
temperature,  and  the  passage  of  pigmented  urine  (intermittent 
haematinuria). 

Pernicioits  Intermittent. — i.  After  the  chill,  instead  of  the  fever 
there  is  feeble  heart-action  and  collapse. 

2.  In  the  third  stage  there  is  profuse  sweating  and  collapse. 

3.  During  the  chill  there  is  dangerous  heart-failure. 

4.  In  the  second  stage  there  is  coma  or  violent  delirium. 

5.  In  the  second  stage  there  is  congestion  of  the  lungs,  with 
cough,  dyspnoea,  and  profuse  mucous  expectoration. 

6.  In  the  second  stage  there  is  congestion  of  the  stomach, 
with  pain,  vomiting,  and  haematemesis  ;  or  congestion  of  the  in- 
testines with  pain,  purging,  and  bloody  stools. 

Treatment. — The  inhabitants  of  malarial  districts  learn  to  se- 
lect the  situation  of  their  houses,  to  look  after  their  drainage, 
and  to  avoid  the  night  air. 

Persons  who  have  to  pass  a  short  time  in  a  malarial  district 
do  well  to  take  from  six  to  ten  grains  of  quinine  after  breakfast 
every  morning. 

To  abort  a  paroxysm  we  may  give  a  hypodermic  of  one-fifth 
of  a  grain  of  muriate  of  pilocarpin,  and  one-eighth  of  a  grain  of 


THE   MALARIAL   DISEASES.  '  459 

sulphate  of  morphine,  together,  or  a  full  dose  of  opium,  or 
drachm  doses  of  chloroform,  or  antifebrin,  or  antipyrin. 

To  cure  the  disease  we  may  use  quinine.  The  ordinary  dose 
is  from  twelve  to  twenty  grains  between  the  paroxysms.  The 
efficiency  of  the  quinine  is  much  increased  by  giving  it  in  solu- 
tion.    In  bad  cases  the  dose  must  be  larger. 

In  some  cases  we  do  better  with  Warburg's  tincture  in  cap- 
sules, four  to  eight  capsules  a  day. 

In  some  cases  there  is  an  advantage  in  adding  arsenic  to  the 
quinine. 

In  all  cases  it  is  the  rule  to  continue  the  treatment  for  some 
weeks  after  the  paroxysms  have  stopped. 

In  some  cases  the  paroxysms  cannot  be  stopped  except  by 
change  of  climate. 

Remittent  Fever. 

The  invasion  of  the  symptoms  may  be  sudden,  or  preceded  by 
one  or  more  paroxysms  of  intermittent  fever,  or  by  a  prodromic 
period  of  several  days'  duration. 

The  invasion  of  the  disease  is  marked  by  one  or  more  chills, 
more  or  less  severe.  The  temperature  begins  to  rise  during  the 
chills.  The  patients  suffer  from  headache,  pains  in  the  back  and 
limbs,  a  rapid  pulse,  a  coated  tongue,  nausea,  and  vomiting. 

There  is  a  remission  of  the  fever  in  the  early  morning,  and 
sometimes  a  second  remission  in  the  evening.  The  bowels  are 
constipated.     The  urine  is  acid  and  high-colored. 

The  fever  lasts  for  from  five  to  twenty-one  days  ;  it  termi- 
nates in  recovery,  or  in  death,  or  is  followed  by  intermittent  fever. 

In  the  mild  cases  the  patients  are  not  at  any  time  very  sick, 
and  regularly  recover. 

In  the  severe  cases  the  temperature  is  high  and  nearly  con- 
tinuous, the  tongue  becomes  dry,  the  pulse  is  rapid  and  feeble, 
the  patients  pass  into  the  typhoid  state,  with  delirium  and  diar- 
rhoea. 

In  the  malignant  cases  the  prostration,  the  cerebral  symptoms, 
the  jaundice,  and  the  hemorrhages  from  the  mucous  membranes 
are  marked  symptoms. 

Treatment. — At  the  commencement  of  the  disease  it  is  custom- 
ary to  give  first  a  mercurial  purge  and  then  quinine,  or  War- 
burg's tincture.     If  these  are  of  service  their  use  is  continued  ; 


46o  THE   MALARIAL   DISEASES. 

if  they  exert  no  effect  on  the  disease  they  are  discontinued,  and 
we  fall  back  on  the  nursing  and  the  treatment  of  symptoms,  until 
the  time  for  the  subsidence  of  the  disease,  when  the  quinine  may 
be  tried  again. 

Malarial  Cachexia. 

Either  with  or  without  previous  attacks  of  intermittent  or 
remittent  fever,  persons  may  become  the  subjects  of  malarial 
cachexia. 

The  essential  feature  of  malarial  cachexia  seems  to  be  the  de- 
struction of  red  blood-cells  and  the  consequent  anaemia  with  its 
attendant  symptoms.  There  is  also  regularly  hypertrophy  of  the 
spleen. 

The  patients  become  pale,  feeble,  languid,  and  emaciated. 
They  suffer  from  headache,  neuralgic  pains,  and  disturbances  of 
digestion. 

The  condition  of  these  patients  is  often  very  miserable,  and 
it  is  possible  for  them  to  die  with  extreme  anaemia  or  leukaemia. 

Treatment. — The  most  important  point  in  the  treatment  of 
these  patients  is  their  removal  from  the  malarial  district  to  one 
where  no  malaria  exists.  In  addition  we  employ  arsenic,  iron, 
and  measures  likely  to  improve  the  digestion  and  the  nutrition. 

The  Malarial  Diseases  of  New  York.         ^ 

1.  The  hitermittent  Type. — {a)  The  patients  have  regular  and 
complete  paroxysms  of  intermittent  fever. 

{b)  They  have  paroxysms  of  fever  alone,  the  temperature  usu- 
ally not  over  ioo°  F.,  at  regular  or  irregular  intervals,  in  the 
evening  or  at  night. 

{c)  They  have  paroxysms  without  fever,  but  with  malaise, 
headache,  sleeplessness,  irritability  of  temper,  palpitation  of  the 
heart,  loss  of  appetite,  nausea,  disturbances  of  the  functions  of 
the  liver,  and  abnormal  sensations.  The  paroxysms  come  on  in 
the  evening  or  at  night,  at  regular  or  irregular  intervals. 

2.  The  Remittent  Type,  {a)  The  patients  have  a  morning  tem- 
perature of  about  ioo°  F.,  and  an  afternoon  temperature  of  from 
104°  to  106°  F.  They  do  not  look  very  sick.  I  have  seen  a  num- 
ber of  such  cases  in  children.  In  women  after  childbirth  such 
a  fever  is  not  infrequent.  It  may  give  rise  to  much  alarm  and  to 
fears  of  pelvic  inflammation.     It  is  a  curious  feature  of  this  fever 


THE   MALARIAL   DISEASES.  46 1 

that,  while  in  some  cases  it  yields  promptly  to  quinine,  in  other 
cases  it  continues  in  spite  of  all  treatment  until  the  patients  are 
taken  out  of  New  York. 

[b)  The  patients  have  fever,  103°  to  104°  F.,  with  headache 
and  moderate  prostration,  for  two  weeks,  and  then  get  well  with- 
out further  trouble. 

{c)  The  patients  have  a  little  fever,  99°  to  102°  F.,  higher 
every  evening.  This  fever  lasts  for  weeks  and  months.  The  pa- 
tients are  not  usually  in  bed,  but  feel  very  miserable.  They  have 
headache,  disturbances  of  digestion,  abnormal  sensations,  lose 
flesh  and  strength. 

3.  The  Malarial  Cachexia. — This  follows  the  ordinary  type  of 
the  milder  forms  of  malarial  cachexia. 

Treatment. — There  is  a  very  great  difference  in  different  pa- 
tients as  to  the  effect  of  remedies.  Quinine,  arsenic,  or  War- 
burg's tincture  act  quickly  and  efficiently  for  some,  while  for 
others  they  are  absolutely  useless.  Attention  to  the  digestion, 
the  general  health,  and  change  of  climate  are  always  necessary. 


WHOOPING-COUGH. 


(Pertussis.) 


An  infectious  disease  characterized  by  inflammation  of  the 
respiratory  tract  and  a  peculiar  paroxysmal  cough. 

Lesions. — There  is  catarrhal  inflammation  of  the  nose,  larynx, 
trachea,  and  bronchi,  sometimes  broncho-pneumonia. 

The  poison  of  the  disease  has  not  been  demonstrated.  It  is 
apparently  given  off  with  the  breath,  floats  in  the  air,  and  is 
taken  into  the  bronchi. 

The  disease  is  contagious  from  person  to  person.  One  attaclv 
protects  against  subsequent  exposure.  It  often  accompanies  epi- 
demics of  measles. 

The  period  of  incubation  lasts  for  two  weeks. 

Tlie  invasion  begins  with  the  symptoms  of  the  inflammation 
of  the  nose,  larynx,  trachea,  and  bronchi,  in  varying  degrees  of 
severity.  Tlie  bronchitis  is  the  prominent  symptom.  These 
symptoms  last  for  one  or  more  weeks  before  the  appearance  of 
the  paroxysmal  cough.  This  cough  comes  on  in  attacks,  during 
which  the  patient  holds  his  breath  and  then  takes  a  long  inspi- 
ration with  the  characteristic  stridulous  sound. 

In  the  mild  cases  the  bronchitis  is  not  severe,  the  paroxysms 
of  cough  not  very  frequent,  and  the  patients  suffer  but  little. 

In  other  cases  the  paroxysms  are  so  frequent  and  accom- 
panied with  so  much  vomiting,  that  the  patient's  health  may  suffer 
to  a  dangerous  degree. 

The  worst  cases  are  those  which  are  complicated  with  bron- 
cho-pneumonia. 

The  disease  lasts  for  from  six  to  twelve  weeks. 

Treahnent.  —  lnha.\?itions  of  creosote^  of  carbolic  acid,  may  be 
of  service. 

The  bronchitis  may  be  alleviated  by  the  use  of  opium,  ipecac, 
belladonna,  or  hydrocyanic  acid  ;  or  by  counter-irritants  applied 
to  the  wall  of  the  chest. 

Applications  of  cocaine  to  the  nose  may  be  of  service. 

Strychnia,  conium,  arsenic,  quinine,  the  bromides,  valerian, 
asafoetida,  and  chloral  are  given  as  empirical  remedies. 

Change  of  climate  is  often  of  s^reat  service. 


MUMPS. 


(Infectious  Parotitis.) 

An  infectious  disease  characterized  by  constitutional  symp- 
toms and  inflammation  of  the  salivary  glands. 

Lesions. — Either  one  or  both  parotid  or  submaxillary  glands 
are  inflamed.  The  inflammation  only  goes  on  to  the  point  of 
congestion  and  swelling  of  the  glands.  Occasionally  the  tes- 
ticles or  the  mammary  glands  are  inflamed  in  the  same  way. 

The  poison  of  the  disease  has  not  been  demonstrated.  The 
disease  is  contagious  from  person  to  person. 

The  period  of  incubation  is  from  fourteen  to  twenty-one  days. 

The  symptoms  may  begin  with  the  constitutional  disturbances, 
or  with  the  inflammation  of  the  salivary  glands,  or  with  both 
together. 

The  constitutional  symptoms  are  :  fever,  headache,  nausea, 
restlessness,  irritability,  and  prostration. 

The  local  symptoms  consist  in  the  pain  and  swelling  of  the 
inflamed  glands.     With  this  there  is  often  some  pharyngitis. 

The  inflammation  of  the  glands  reaches  its  height  in  from 
three  to  six  days,  remains  stationary  for  one  or  two  days,  and 
then  subsides. 

If  only  one  parotid  is  inflamed,  or  if  in  both  parotids  the  in- 
flammation begins  at  the  same  time,  the  disease  lasts  about  a 
week.  If  the  parotids  are  inflamed  successively,  the  disease  is 
protracted  for  two  weeks. 

The  complicating  inflammations  of  the  testicles  or  mammae 
add  very  much  to  the  discomfort  of  .the  patient  and  protract 
the  disease. 

Most  cases  of  mumps  run  a  mild  course.  There  may,  how- 
ever, be  feeble  heart-action,  or  excessive  fever,  or  delirium. 

Treatment  is  directed  to  the  alleviation  of  symptoms. 


ANEMIA. 


In  health,  while  the  different  constituents  of  the  blood — the 
red  cells,  the  white  cells,  and  the  plasma — are  constantly  under- 
going change,  destruction,  and  reproduction,  their  relative  quan- 
tities continue  the  same.  In  exactly  what  way,  and  exactly 
where,  the  death  and  new  formation  of  the  blood-cells  take  place 
we  do  not  definitely  know. 

In  disease  the  blood  may  be  changed  by  a  diminution  in  the 
number  of  red  cells,  a  diminution  in  the  quantity  of  haemoglobin, 
or  an  increase  in  the  number  of  white  cells. 

When  the  change  consists  in  a  diminution  in  the  number  of 
red  cells  and  in  the  quantity  of  haemoglobin,  the  patient  is  said 
to  suffer  from  "  anaemia."  If  such  changes  in  the  blood  are  well 
marked,  we  may  find  in  addition  a  variation  in  the  form  and 
size  of  the  red  cells,  yellow  spherical  microcytes,  and  nucleated 
red  cells. 

It  is  evident  that  a  diminution  in  the  number  of  red  cells  must 
be  due  to  a  diminished  new  formation,  or  an  increased  destruc- 
tion ;  but  to  tell  which  of  these  is  the  efficient  cause  in  each  case 
of  anaemia  is  very  difficult. 

While  our  knowledge  of  anaemia  is  still  so  imperfect  that  we 
cannot  tell  certainly  the  relationship  of  its  different  forms,  it  is 
necessary,  for  purposes  of  prognosis  and  treatment,  to  adopt  some 
form  of  classification.  For  this  purpose  I  find  it  convenient  to 
class  all  the  cases  of  anaemia  into  four  groups  :  i.  Secondary 
Anaemia  ;  2,  the  Primary  Anaemia  of  Young  Women  ;  3,  Perni- 
cious Anaemia  ;  4,  Anaemia  apparently  intermediate  in  character 
between  simple  and  pernicious  anaemia. 

I.  Secondary  Anemia. 

Secondary  anaemia  is  of  very  frequent  occurrence.  It  is 
caused  by  Bright's  disease,  phthisis,  malaria,  cancer,  uterine  dis- 
ease, any  chronic  and  exhaustive  disease,  and  hemorrhage.      It 


AN/EMIA.  465 

also  occurs,  especially  in  women,  in  persons  whose  general  health 
is  bad,  although  they  have  no  definite  disease. 

In  these  patients  the  pallor  of  the  skin  and  mucous  mem- 
branes is  usually  very  marked.  The  diminution  in  the  quantity 
of  haemoglobin  and  the  number  of  red  cells  is  never  very  great. 
Of  the  other  symptoms  which  may  be  present,  it  is  always  diffi- 
cult to  tell  how  many  are  due  to  the  primary  disease  and  how 
many  to  the  anaemia. 

In  the  treatment  of  these  patients  the  essential  parts  are  the 
treatment  of  the  primary  disease  and  the  improvement  of  the 
patient's  general  health  by  food,  climate,  and  mode  of  life.  Iron 
and  oxygen  are  only  accessory  parts  of  the  treatment,  and  often 
of  little  or  no  service. 

2.  The  Primary  An.emia  of  Young  Women. 

Synonym. — Chlorosis. 

Causes. — The  disease  occurs  regularly  in  women  between  the 
ages  of  fourteen  and  thirty  years.  It  is  said  by  some  authors 
that  it  never  occurs  in  the  male,  but  this  certainly  is  an  error. 
Young  males  are  also  affected  by  the  disease,  although  in  small 
proportion  compared  to  the  number  of  women  afifected.  In 
women  the  disease  is  a  very  common  one,  and  is  observed  both 
in  persons  living  in  cities  and  in  those  living  in  the  country, 
among  the  rich  and  among  the  poor,  in  the  midst  of  perfect 
health  and  after  depressing  conditions.  It  is  one  of  the  curious 
features  of  the  disease  that  a  strong,  healthy  girl,  eating  well, 
sleeping  well,  taking  plenty  of  out-door  exercise,  can,  without 
discoverable  cause,  become  anaemic.  We  are  ignorant  of  the 
causes  of  the  disease  and  of  the  causes  of  the  changes  in  the 
blood.  Whether  there  is  an  increased  destruction  of  red  blood- 
cells  and  of  haemoglobin  or  a  dimished  production  is  uncertain. 

Syjnptoms. — The  most  important  symptom  is  the  change  in  the 
composition  of  the  blood.  There  is  always  a  diminution  in  the 
quantity  of  haemoglobin  and  usually  a  decrease  in  the  number 
of  red  blood-cells.  The  red  blood-cells  have  to  be  counted  with 
the  Thoma-Zeirs  haemacytometer,  or  with  one  of  the  other  in- 
struments made  for  that  purpose,  and  we  reckon  5,000,000  red 
blood-cells  to  the  cubic  millimetre  as  the  standard  in  health. 
The  estimation  of  haemoglobin  is  easily  made  with  the  Fleischl 
haemometer.     The  counting  of  the  red  blood-cells  is  tedious,  and 


466  ANEMIA. 

the  liability  to  error  considerable.  The  estimation  of  the  haemo- 
globin is  quickly  and  easily  done,  and  answers  alone  for  the  larger 
number  of  cases.  In  many  patients  a  doubtful  diagnosis  is 
settled  at  once  by  the  estimation  of  the  haemoglobin.  The  loss  of 
haemoglobin  is  always  marked,  it  falls  to  from  twelve  to  seventy- 
five  per  cent.  It  is  often,  but  by  no  means  always,  out  of  pro- 
portion to  the  loss  of  red  blood-cells,  thirty-eight  per  cent  of 
haemoglobin,  for  example,  with  4,308,000  red  cells.  The  ordi- 
nary rule,  therefore,  in  these  patients  is  to  find  the  red  blood- 
cells  not  much  below  4,000,000  to  the  cubic  millimetre,  while  the 
haemoglobin  is  below  fifty  per  cent.  But  it  is  by  no  means  a  rare 
exception  to  have  the  number  of  red  cells  below  2,000,000.  A 
patient  with  1,500,000  red  blood-cells  and  twenty  per  cent,  of 
haemoglobin  can  be  considered  an  advanced  case  of  simple  anae- 
mia. As  the  patients  improve  under  treatment,  the  number  of 
red  blood-cells  and  the  quantity  of  haemoglobin  increase,  the 
number  of  red  blood-cells  reaches  the  normal  standard  with  con- 
siderable certainty  ;  but  it  is  much  harder  to  get  the  haemoglobin 
above  ninety  per  cent. 

The  skin  and  mucous  membranes  are  usually  distinctlv  pale, 
although  seldom  of  the  absolute  whiteness  that  belongs  to  per- 
nicious anaemia  ;  but  it  must  be  remembered  that  persons  may 
look  pale  with  a  normal  composition  of  the  blood,  and  may  look 
of  good  color  although  they  are  really  anaemic.  It  is  for  this 
reason  that  the  actual  estimation  of  the  haemoglobin  is  of  so 
much  consequence. 

The  patients  remain  well  nourished  or  they  become  some- 
what emaciated.  The  loss  of  muscular  strength  and  the  indispo- 
sition to  bodily  or  mental  exertion  are  well  marked.  Irritability 
of  temper,  a  loss  of  interest  in  ordinary  occupations,  neuralgic 
pains  in  different  parts  of  the  body,  and  a  great  variety  of  hys- 
terical symptoms  are  often  present.  When  a  young  girl  com- 
plains that  she  cannot  ride,  or  take  long  walks,  or  play  tennis  as 
she  has  been  accustomed  to  ;  when  she  is  dull  about  her  lessons, 
cross  and  peevish  with  her  family,  listless  and  headachy,  we  must 
always  think  of  anaemia  as  a  probable  cause. 

The  heart's  action  is  rapid,  with  dyspnoea  on  exertion.  The 
dyspnoea  increases  as  the  anaemia  progresses.  In  the  extreme 
cases  the  patients  cannot  even  get  out  of  bed  without  fainting. 
There  is  often  a  systolic  murmur  diffused  over  the  praecordial 
area,  or  with  its  maximum  intensity  at  the  second  left  intercostal 


AN/EMIA.  467 

space,  or  at  the  apex.  Occasionally  the  heart  is  enlarged,  the  en- 
largement disappearing  as  the  patients  recover  from  the  anaemia. 
These  cardiac  symptoms  are  the  direct  result  of  the  anaemia. 
We  must  not  allow  them  to  mislead  us  into  the  belief  that  the 
patients  have  either  a  disease  or  a  neurosis  of  the  heart. 

The  patients  may  be  annoyed  by  a  cough  due  to  the  condi- 
tion of  the  pharynx  or  to  In'steria.  They  may  from  time  to 
time  cough  up  small  quantities  of  blood.  It  is  not  always  easy 
to  distinguish  these  patients  from  cases  of  commencing  pulmo- 
nary tuberculosis. 

Disturbances  of  the  functions  of  the  stomach  are  very  fre- 
quently present  and  are  often  so  marked  as  to  attract  more  atten- 
tion than  does  the  anaemia  by  which  they  are  caused.  The 
patients  complain  of  gastric  pain,  made  worse  by  the  ingestion 
of  food,  loss  of  appetite,  nausea,  vomiting,  and  vomiting  of 
blood.  It  is  of  great  importance  not  to  mistake  these  patients 
for  cases  of  catarrhal  gastritis  or  of  ulcer  of  the  stomach,  for 
it  will  be  found  that  all  the  gastric  symptoms  disappear  if  the 
anaemia  is  relieved.  The  bowels  are  often  constipated,  per- 
haps not  more  so  than  is  the  case  in  young  women  who  are  not 
anaemic. 

The  urine  is  often  turbid  and  alkaline.  It  mav  contain  small 
quantities  of  albumin  without  disease  of  the  kidneys.  An  anaemic 
patient  with  a  little  albumin  in  the  urine  and  oedema  of  the  legs 
or  face  may  readily  be  mistaken  for  a  case  of  nephritis. 

The  menstrual  flow  is  usually  light-colored,  scanty,  irregular, 
or  stops  altogether  ;  but  it  is  sometimes  in  excess. 

In  the  more  severe  cases  there  is  an  irregular  febrile  move- 
ment, the  temperature  higher  in  the  afternoon,  but  not  often 
higher  than  101°  F. 

The  cases  vary  as  to  the  rapidity  with  which  the  symptoms 
are  developed,  their  severity,  their  number,  and  the  predomi- 
nance of  one  or  more  symptoms  over  others.  In  the  mild  cases 
the  patients  hardly  feel  sick,  and  do  not  understand  why  bodily 
and  mental  exertion  are  becoming  difficult  to  them.  In  the  more 
severe  cases  the  shortness  of  breath  and  muscular  feebleness  ren- 
der the  patients  unable  to  work,  while  the  nervous  and  gastric 
symptoms  give  them  much  annoyance.  The  worst  patients  can- 
not be  distinguished  from  cases  of  pernicious  anaemia.  They  are 
in  bed,  extremely  feeble,  of  a  ghastly  white  color,  with  fever, 
either  delirious  or  stupid,  bleeding  from   the   mouth   and  from 


468  ANyEMIA. 

the  stomach,  vomiting  from  time  to  time  ;  but  even  from  this  un- 
promising condition  they  can  recover  altogether. 

In  some  patients  the  anaemia  with  its  symptoms  are  devel- 
oped very  rapidly,  sometimes  even  within  a  few  days.  More  fre- 
quently they  are  developed  slowly,  so  that  several  months  elapse 
before  the  patient  is  much  inconvenienced. 

Occasionally  we  see  women  who  have  gone  for  three  or  four 
years  before  they  have  had  to  give  up  worl<,  slowly  getting  more 
anaemic,  but  not  adopting  any  plan  of  treatment. 

The  prognosis  of  the  disease  depends  upon  its  treatment.  If 
properly  treated  the  patients  recover,  but  the  treatment  must  be 
continued  for  a  long  time  and  relapses  must  be  expected.  The 
only  cases  which  are  likely  to  prove  fatal  are  those  with  vomiting 
of  blood,  and  those  in  which  the  haemoglobin  is  less  than  twenty 
per  cent,  and  the  number  of  red  blood-cells  less  than  two  million 
to  the  cubic  millimetre. 

Treatment. — In  the  mild  cases  without  much  prostration  or 
gastric  disturbance,  all  that  is  necessary  is  the  ingestion  of  iron. 
The  best  preparation  of  iron  for  ail  cases  of  anaemia  is  the  sulphate, 
the  best  time  to  take  it  is  after  meals,  and  the  quantity  should 
be  from  twelve  to  twenty-four  grains  in  the  twenty-four  hours. 

In  the  cases  with  pain  in  the  stomach,  nausea,  and  vomiting, 
the  food  must  be  restricted,  but  the  food  and  iron  can  be  taken 
by  the  stomach  even  if  the  patients  vomit  blood.  It  is,  however, 
necessary  to  keep  the  patients  in  bed. 

In  the  advanced  cases  with  marked  dyspnoea  and  feebleness, 
it  is  important  at  first  to  keep  the  patients  in  bed,  with  massage 
in  addition  to  the  use  of  iron. 

There  are  some  persons  who  at  first  either  cannot  or  will  not 
take  iron.  In  these  persons  there  is  an  advantage  in  the  use  of 
inhalations  of  oxygen  gas  continued  for  ten  minutes  two  or  three 
times  a  day.  As  soon  as  they  have  learned  to  take  iron  enough 
the  oxygen  becomes  unnecessary. 

In  all  tlie  cases  of  anaemia  it  is  absolutely  necessary  for  the 
bowels  to  move  every  day.  If  they  do  not  move  the  iron  treat- 
ment will  not  exert  its  specific  effects  in  changing  the  composi- 
tion of  the  blood. 

It  is  necessary  to  examine  the  blood  of  these  patients  every 
week,  so  as  to  be  sure  that  the  quantity  of  haemoglobin  and  the 
numbers  of  the  red  blood-cells  are  really  increasing  as  they 
oua:ht  to  do. 


ANy?<:MIA.  469 


3.  Pernicious  Anemia. 

Synonyms. — Idiopathic  Anaemia  ;  Essential  Anaemia. 

Lesions. — In  some  of  the  persons  who  have  pernicious  anaemia 
there  are  found  after  death  :  cancer  of  the  stomach,  chronic  gas- 
tritis, degeneration  or  atrophy  of  the  gastric  tubules,  the  anchy- 
lostoma  duodenale  or  bothriocephalus  latus  in  the  intestine,  or 
chronic  nephris.  It  is  believed  by  some  that  such  lesions  may 
cause  pernicious  anaemia  ;  by  others  that  their  association  in  the 
same  person  is  accidental. 

As  the  results  of  the  anaemia  we  may  also  find  fatty  degener- 
ation of  the  wall  of  the  heart,  degeneration  of  the  hepatic  cells, 
the  renal  cells,  the  walls  of  the  arteries  and  capillaries. 

In  the  blood  the  number  of  red  cells  is  very  much  diminished. 
There  may  be  less  than  one  million  red  cells  to  the  cubic  milli- 
metre. Many  red  cells  are  found  of  abnormal  size  or  shape,  or 
containing  nuclei.  Yellow,  spherical  microcytes,  about  one- 
fourth  the  size  of  the  red  blood-cells,  are  often  present.  The 
entire  quantity  of  haemoglobin  is  diminished  often  below  twenty 
per  cent.,  but  not  the  quantity  belonging  to  the  red  cells  which 
are  left  in  the  blood.  The  individual  red  cells  are  still  rich  in 
haemoglobin. 

In  the  marrow  of  the  long  bones  there  are  found  nucleated 
red  blood  cells  and  cells  enclosing  old  red  cells. 

Hunter  has  lately  called  attention  to  the  condition  of  the 
liver.  He  has  found  in  it,  with  pernicious  anaemia,  always  an 
excess  of  iron.  The  iron  is  in  the  form  of  pigment  granules  in 
the  liver-cells,  which  form  the  outer  two-thirds  of  each  lobule. 

Nature  of  the  Disease. — Two  entirely  different  views  are  held 
concerning  the  nature  of  pernicious  anaemia.  One  view  is  that 
it  is  simply  an  advanced  form  of  anaemia,  which  can  be  produced 
by  a  variety  of  causes.  The  other  that  it  is  a  primary  disease, 
entirely  distinct  from  other  forms  of  anaemia. 

The  study  of  the  disease  made  by  Hunter  has  led  him  to  the 
following  conclusions  : 

1.  Pernicious  anaemia  is  a  special  disease. 

2.  Its  essential  pathological  feature  is  an  excessive  destruction 
of  blood-cells. 

3.  The  most  constant  anatomical  change  is  the  presence  of  an 
excess  of  iron  in  the  liver. 


470  ANEMIA. 

4.  This  condition  of  the  liver  distinguishes  pernicious  anaemia 
from  symptomatic  anaemia. 

5.  The  disintegration  of  the  red  cells  is  effected  chiefiy  in  the 
portal  circulation,  especially  in  the  spleen  and  liver.  The  de- 
struction is  effected  by  poisonous  agents  absorbed  from  the 
intestinal  tract. 

Symptoms. — The  disease  regularly  begins  slowly  and  insid- 
iously, much  less  frequently  rapidly. 

The  color  of  the  skin  and  , mucous  membranes  becomes  pale, 
often  with  a  dusky  or  yellow  tinge. 

There  is  gradual  loss  of  muscular  and  mental  strength. 

The  functions  of  the  stomach  and  intestines  are  disturbed. 

There  is  palpitation  of  the  heart,  dyspnoea  on  exertion,  at- 
tacks of  syncope,  a  systolic  murmur  heard  at  the  apex  or  in  the 
second  left  interspace. 

There  may  be  hemorrhages  into  the  retina,  into  the  skin,  from 
the  nose,  mouth,  bronchi,  stomach,  or  intestines. 

At  some  time  in  the  course  of  the  disease  there  is  an  irregular 
febrile  movement. 

After  a  time  the  patients  lose  flesh  as  well  as  strength,  and 
the  entire  condition  is  that  of  very  great  feebleness. 

The  disease  lasts  for  weeks,  months,  years.  The  patients 
steadily  get  worse,  but  often  with  intervals  of  considerable  im- 
provement. The  cases  which  run  their  course  within  a  few  weeks 
are  the  least  frequent. 

The  prognosis  is  bad. 

Treatment. — The  most  efficient  drug  in  the  treatment  of  the 
disease  is  arsenic,  which  must  be  given  in  considerable  doses. 
Iron,  oxygen,  feeding,  and  nursing  are  accessory  measures. 

4.   Intermediate  Anemia. 

Anaemia  which  clinically  holds  an  intermediate  place  be- 
tween simple  anaemia  and  pernicious  anaemia. 

I  describe  under  this  indefinite  name  a  group  of  cases  of  which 
I  see  a  considerable  number,  and  which  I  am,  therefore,  for  my 
own  convenience,  obliged  to  arrange  into  some  sort  of  a  class. 
I  admit  that  many  of  these  cases  may  possibly  be  examples  of  a 
mild  form  of  pernicious  anaemia,  and  that  it  is  not  easy  to  distin- 
guish some  of  them  from  the  secondary  anaemias. 

The  patients  are  both  males  and  females  between  the  ages  of 


AM/EMIA.  471 

forty  and  sixty  years.  In  some  of  them  there  is  a  history  of  over- 
work ;  in  some  of  them  it  takes  some  time  to  show  that  they 
have  no  obscure  malignant  disease  ;  but  in  many  the  disease 
comes  on  without  any  discoverable  cause. 

The  blood  shows  a  diminution  in  the  quantity  of  haemoglobin 
and  the  number  of  red  blood-cells,  but  not  to  an  extreme  degree. 
The  haemoglobin  is  not  usually  below  fifty  per  cent.,  nor  the  red 
blood-cells  below  3,000,000  to  the  cubic  millimetre.  The  rela- 
tive diminution  of  the  haemoglobin  and  of  the  red  cells  is  more 
like  that  of  simple  anaemia  than  that  of  pernicious  anaemia. 

The  change  in  the  color  of  the  skin,  of  the  mucous  membranes, 
and  of  the  sclerotic  is  very  marked.  These  are  of  a  whiteness 
greater  than  one  would  expect  with  the  degree  of  anaemia.  In 
this  way  the  cases  resemble  those  of  secondary  anaemia.  Some 
of  the  patients  lose  flesh,  others  do  not.  Dyspnoea  is  not  a 
marked  feature.  The  functions  of  the  stomach  and  intestines 
are  often  disturbed.  The  most  marked  feature  is  the  loss  of 
muscular  strength  and  the  indisposition  to  mental  exertion.  The 
patients  improve  greatly  under  treatment,  but  yet  never  get 
quite  well.  They  continue  to  live  for  many  years.  Most  of 
them  have  passed  out  of  my  observation  while  still  in  good 
condition  ;  some  have  died  from  intercurrent  diseases  ;  a  single 
one  died  as  if  with  pernicious  anaemia. 

Treatment. — These  patients  are  improved  by  change  of  cli- 
mate, exercise,  diet,  and  by  any  measures  which  improve  their 
general  health.  Small  doses  of  arsenic,  combined  with  large 
doses  of  iron,  increase  the  quantity  of  haemoglobin  and  the  num- 
ber of  red  blood-cells. 

If  we  compare  the  different  forms  of  anaemia  as  regards  their 
treatment,  we  find  that  : 

1.  In  secondary  anaemia  attention  to  the  general  health  is  of 
principal  importance,  while  iron  and  arsenic  are  of  much  less 
consequence. 

2.  In  the  primary  anaemia  of  young  persons  iron  in  large 
doses  is  a  specific. 

3.  In  pernicious  anaemia  arsenic  in  large  doses  gives  the  best 
results. 

4.  In  the  intermediate  form  of  anaemia  we  do  best  with  arsenic 
in  small  doses,  iron  in  large  doses,  and  attention  to  the  general 
health. 


472  LEUKEMIA. 


Leukemia. 


This  is  a  disease  characterized  by  diminution  in  the  number 
of  red  blood-cells  and  the  quantity  of  haemoglobin,  increase  in 
the  number  of  white  blood-cells,  enlargement  of  the  spleen,  lym- 
phatic glands,  and  marrow  of  the  bones. 

Lesions. — The  specific  gravity  of  the  blood  is  lowered.  Its 
color  is  light-red  or  even  whitish,  looking  like  pus  and  blood 
mixed.  The  number  of  the  red  cells  is  diminished.  The  white 
blood-cells  are  very  much  increased  in  number  ;  the  increase  in 
the  number  of  the  larger  white  cells  is  especially  marked  in  the 
cases  in  which  the  spleen  is  enlarged. 

The  marrow  of  the  bones  is  hypertrophied,  of  yellow  or  red 
color,  with  an  increased  growth  of  both  the  cells  and  stroma. 

The  spleen  is  in  most  cases  much  enlarged,  this  enlargement 
being  a  simple  hypertrophy. 

The  lymphatic  glands  are  often  hypertrophied,  or  tumors 
composed  of  lymphatic  glandular  tissue  are  formed  in  the  liver, 
kidneys,  lungs,  stomach,  intestines,  or  peritoneum. 

There  may  be  extravasations  of  blood  in  any  part  of  the  body. 
There  may  be  an  inflammation  of  the  retina  resembling  that 
which  complicates  Bright's  disease. 

There  may  be  fatty  degeneration  of  the  walls  of  the  heart. 

Causes. — The  disease  has  been  observed  in  persons  between 
the  ages  of  eight  weeks  and  seventy  years.  It  occurs  most  fre- 
quently between  the  ages  of  thirty  and  forty  years.  It  is  more 
frequent  in  man  than  in  woman. 

In  some  patients  the  disease  seems  to  be  secondary  to  malarial 
poisoning,  to  syphilis,  to  blows  on  the  spleen,  or  to  starvation. 

Symptoms. — The  cases  with  hypertrophy  of  the  spleen,  the 
lymphatic  glands,  and  the  marrow  are  the  most  common.  Next 
in  frequency  are  those  with  hypertrophy  of  the  spleen  and  mar- 
row ;  next,  those  with  hypertrophy  of  the  lymphatic  glands  and 
marrow  ;  while  the  least  frequent  are  those  with  hypertrophy  of 
the  marrow  alone. 

The  symptoms  due  to  the  changes  in  the  blood  are  present  in 
all  the  cases. 

The  symptoms  begin  and  go  on  slowly  and  gradually  ;  either 
the  change  in  the  patient's  general  condition  or  the  enlargement 
of  the  spleen  or  glands  may  first  attract  attention. 


PSEUDO-LEUK.KMIA.  473 

The  change  in  the  color  of  tlie  skin  and  mucous  membranes 
is  usually  well  marked,  the  patient  becoming  extremely  white. 
Occasionally,  however,  the  color  remains  natural  for  a  long  time. 

There  is  a  gradual  loss  first  of  strength,  and  then  of  fiesh. 
The  mental  faculties  may  remain  for  a  long  time  unimpaired,  or 
they  may  become  dull  and  sluggish,  with  peevishness  and  irri- 
tability of  temper. 

The  eyeisight  may  be  impaired  by  the  complicating  retinitis. 

The  heart's  action  becomes  feeble,  irritable,  with  a  systolic 
murmur,  dyspnoea,  and  liability  to  attacks  of  syncope. 

Priapism  is  a  curious  symptom  which  has  been  present  in  a 
large  number  of  cases. 

There  may  be  pain  after  eating,  nausea,  and  vomiting. 

Menstruation  is  scanty  and  irregular.  There  may  be  a  mod- 
erate amount  of  subcutaneous  dropsy. 

The  temperature  remains  normal,  or  from  time  to  time  there 
is  an  irregular  febrile  movement. 

Hemorrhages  are  common — from  the  nose,  gums,  bronchi, 
stomach,  intestines,  uterus,  bladder.  The  largest  bleedings  are 
those  behind  the  peritoneum,  which  may  cause  death  within  a 
short  time. 

The  enlargement  of  the  spleen,  glands,  and  liver  is  easily 
recognized. 

The  disease  regularly  lasts  for  months  or  years,  with  periods 
of  exacerbation  and  of  improvement. 

The  prognosis  is  bad,  but  a  few  cases  of  cure  have  been  re- 
ported. 

Treatment.  —The  drugs  most  frequently  employed  are  arseni-c, 
phosphorus,  and  iron.  The  hypertrophy  of  the  spleen  has  been 
treated  by  electricity,  interstitial  injections,  and  extirpation, 

Pseudo-Leukemia. 

Synonyms. — ^Ansemia  Lymphatica  ;  Hodgkin's  Disease. 

A  disease  characterized  by  a  progressive  decrease  in  the  num- 
ber of  red  blood-cells,  an  enlargement  of  the  lymphatic  glands, 
and  new  growths  of  lymphatic  glandular  tissue. 

Lesions. — The  changes  in  the  blood  consist  simply  in  a  diminu- 
tion in  the  number  of  red  blood-cells,  without  anv  increase  in  the 
number  of  white  cells. 

Of  the  lymphatic  glands,  one  or  more  groups  are  enlarged  in 


474  PSEUDO-LEUK.EMIA. 

the  following  order  of  frequency  :  the  cervical  glands,  the  axil- 
lary, the  inguinal,  the  retro-peritoneal,  the  bronchial,  the  medi- 
astinal, and  the  mesenteric.  Of  these  groups  of  glands  those  on 
one  or  on  both  sides  of  the  body  may  be  involved.  The  enlarge- 
ment of  the  glands  is  a  simple  hypertrophy,  with  an  excess  either 
of  the  stroma  or  of  the  cells. 

The  new  growths  of  lymphatic  glandular  tissue  are  found  in 
the  spleen,  the  liver,  the  oesophagus,  the  stomach,  the  intestines, 
the  peritoneum,  the  kidneys,  the  lungs,  the  pleura,  the  ovaries,  the 
testicles,  the  dura  mater,  and  the  skin. 

The  marrow  of  the  bones  is  changed  in  the  same  way  as  in 
leukaemia. 

Causes. — The  disease  is  more  frequent  in  males  than  in  females, 
in  the  proportion  of  three  to  one.  It 'has  been  observed  in  per- 
sons between  the  ages  of  one  and  seventy  years,  but  it  is  most 
frequent  in  early  and  late  adult  life. 

Symptoms. — Both  the  changes  in  the  glands,  the  new  growths 
of  glandular  tissue,  and  the  changes  in  the  blood  contribute  to 
the  symptoms. 

The  enlarged  cervical  glands  may  press  on  the  pharynx,  the 
larynx,  the  carotids,  and  the  veins  of  the  neck. 

The  enlarged  intra-thoracic  glands  may  press  on  the  trachea, 
the  oesophagus,  the  bronchi,  and  the  descending  vena  cava. 

The  enlarged  glands  in  the  abdomen  may  cause  pain,  they  may 
press  on  the  common  bile-duct  or  the  portal  vein. 

The  enlarged  glands  in  the  pelvic  and  iliac  regions  may  cause 
pain  in  the  thigh  or  along  the  track  of  the  sciatic  nerve,  and 
oedema  of  the  leg. 

The  new  growths  in  the  liver  and  spleen  are  accompanied 
with  the  enlargement  of  these  organs. 

The  changes  in  the  blood  produce  symptoms  like  those  of 
pernicious  anaemia  : 

Feeble  heart-action  with  dyspnoea  on  exertion  ;  bodily  and 
mental  weakness  ;  dropsy;  hemorrhages  ;  nervous  and  hysterical 
symptoms  ;  an  irregular  febrile  movement ;  pain  and  tenderness 
over  the  bones.  Some  of  the  patients,  toward  the  close  of  the 
disease,  develop  delirium,  general  convulsions,  or  coma. 

The  disease  begins  either  with  the  symptoms  belonging  to 
the  anaemia  or  with  those  belonging  to  the  glands.  The  pa- 
tients slowly  get  worse,  both  sets  of  symptoms  becoming  more 
and  more  marked,  but  yet  one  usually  predominating. 


ADDISON'S   DISEASE.  475 

The  patients  finally  die  worn  out,  feeble,  and  emaciated  ;  or 
from  the  pressure  of  the  enlarged  glands  on  the  blood-vessels  or 
air- passages  ;  or  with  cerebral  symptoms;  or  from  some  inter- 
current disease. 

Treatment. — The  most  efficient  methods  of  treatment  seem  to 
be  the  removal  of  the  enlarged  glands  by  operation  and  the 
internal  administration  of  arsenic  or  of  iodine  in  considerable 
doses. 

Addison's  Disease. 

Definition. — A  disease  characterized  by  anaemia,  general  lan- 
guor and  debility,  feeble  heart-action,  irritability  of  the  stomach, 
a  peculiar  change  in  the  color  of  the  skin,  and  disease  of  the 
supra-renal  capsules  (Addison), 

Later  authors  have  included  with  the  disease  cases  of  diseased 
supra-renal  capsules  and  anaemia,  without  pigmentation  of  the 
skin  ;  and  cases  of  pigmented  skin  and  anaemia,  without  disease 
of  the  supra-renal  capsules. 

Lesions. — The  regular  change  in  the  supra-renal  capsules  is  a 
tubeixular  inflammation,  which  results  in  the  conversion  of  the 
capsules  into  masses  of  fibrous  tissue  and  cheesy  matter. 

Less  frequently  the  capsules  have  been  found  atrophied,  or 
absent,  or  the  seat  of  malignant  disease. 

The  change  in  the  skin  consists  in  a  deposition  of  pigment  in 
the  deeper  epithelial  cells  and  in  the  connective-tissue  cells  of 
the  cutis. 

The  spleen  is  sometimes  enlarged. 

In  the  abdominal  sympathetic  there  have  been  found  an 
increase  of  fibrous  tissue  and  a  degeneration  of  the  nerve-fibres 
and  cells. 

In  the  blood  there  is  soinetimes  a  diminution  of  the  number 
of  red  cells  and  the  quantity  of  haemoglobin. 

Nature  of  the  Disease.  —While  we  are  still  very  ignorant  of  the 
nature  of  the  disease,  there  is  a  general  impression  that  the 
disease  of  the  supra-renal  capsules  is  to  be  looked  on  as  a  causa- 
tive lesion. 

G.  Tizzoni  (1889)  has  published  the  results  obtained  from  a 
long  series  of  experiments  on  animals.     He  concludes  : 

1.  In  rabbits  the  destruction  of  one  or  both  supra-renal 
capsules  causes  death. 

2.  Death  takes  place  after  a  few  hours  or  many  months. 


476  ADDISON'S   DISEASE. 

3.  Before  death,  especially  in  the  longer-lived  rabbits,  symp- 
toms are  developed  like  those  of  Addison's  disease  — pigmenta- 
tion of  the  skin,  emaciation,  loss  of  strength,  stupor,  convul- 
sions. 

4.  After  death  lesions  are  found  in  the  cerebrum,  cerebellum, 
cord,  and  peripheral  nerves.  In  the  cerebrum  and  cerebellum 
the  changes  are  diffuse.  In  the  cord  they  are  most  marked  in 
the  lower  cervical  and  upper  dorsal  regions.  They  begin  in  the 
central  canal  and  extend  through  the  gray  and  white  commissures 
to  the  anterior  and  posterior  horns. 

The  lesion  is  a  degeneration  of  the  nerve-fibres  and  ganglion- 
cells,  with  congestion,  hemorrhages,  and  infiltration,  with  leuco- 
cytes. 

Causes. — The  disease  has  been  observed  in  persons  between 
the  ages  of  eleven  and  fifty-eight  years.  It  is  more  common  in 
males  than  in  females.  We  know  nothing  concerning  its  cau- 
sation. 

Symptoms. — There  is  a  gradual  loss  of  muscular  strength. 
The  mind  becomes  dull,  apathetic,  listless  ;  the  temper  is  often 
irritable  and  peevish.  The  heart's  action  is  feeble  and  rapid, 
with  dyspnoea  on  exertion  and  liability  to  attacks  of  dyspnoea. 
The  functions  of  the  stomach  are  often  disturbed,  with  pain, 
nausea,  and  vomiting.  There  may  be  irregular  pains  in  the 
loins,  epigastric,  and  hypochondriac  regions. 

As  the  disease  goes  on,  the  mind  becomes  more  feeble,  and 
the  patients  less  able  to  take  care  of  themselves.  They  may 
suffer  from  vertigo,  from  feelings  of  numbness  in  diffei^ent  parts 
of  the  body,  or  portions  of  the  skin  may  be  anaesthetic. 

As  the  anaemia  is  developed,  the  skin  and  mucous  membranes 
become  pale. 

The  characteristic  brownish  discoloration  appears  in  those 
parts  of  the  skin  which  are  usually  uncovered  by  clothing,  and 
in  the  regions  where  the  skin  is  naturally  darker.  The  mucous 
membrane  of  the  lips,  gums,  and  tongue  may  be  discolored  in 
the  same  way. 

In  the  last  stages  of  the  disease  the  patients  are  exceedingly 
feeble  ;  stupor,  delirium,  general  convulsions,  or  coma  may  be 
developed. 

The  patients  die  from  asthenia,  in  an  attack  of  syncope,  or 
in  convulsions. 

The  disease  is  protracted  for  months  or  years,  with  periods 


ADDISON  S   DISEASE.  477 

of  remission  and  of  exacerbation,  but  the  patients  always  finally 
become  worse. 

Rarely,  the  constitutional  symptoms  are  very  slight  until  a 
few  days  before  death. 

The  discoloration  of  the  skin  may  exist  for  months  or  years 
before  any  of  the  other  symptoms,  or  the  general  symptoms 
may  last  for  a  long  time  before  any  discoloration  of  the  skin  is 
established. 

The  treatment  of  Addison's  disease  is  directed  entirely  to  the 
alleviation  of  symptoms  and  the  comfort  of  the  patient.  For  the 
disease  itself  no  treatment  is  known. 


HYDROPHOBIA. 


An  infectious  disease  belonging  to  dogs,  foxes,  and  wolves, 
and  sometimes  communicated  from  them  to  man  and  to  other 
animals. 

The  poison  of  the  disease  exists  in  the  saliva  and  the  spinal 
cord.  Its  micro-organism  has  not  yet  been  demonstrated.  In 
man  the  disease  is  only  acquired  by  inoculation  from  the  bite  of 
a  rabid  animal.  In  animals  it  appears  to  originate  without  dis- 
coverable cause.  The  disease  may  be  given  to  animals  experi- 
mentally by  inoculation  with  the  saliva  or  the  spinal  cord. 

About  half  of  the  human  beings  who  are  bitten  by  rabid  ani- 
mals escape  the  disease. 

Lesions. — The  lesions  are  in  the  cerebro-spinal  system,  the 
blood-vessels  are  congested,  there  is  perivascular  exudation  of 
leucocytes,  and  there  are  minute  hemorrhages.  According  to 
Gowers,  these  are  particularly  intense  in  the  medulla.  The 
pharynx,  larynx,  trachea,  bronchi,  and  stomach  are  congested. 

The  period  of  incubation  lasts  for  from  only  a  few  days  up  to 
three  months.  Horsley  states  that  the  length  of  time  depends 
upon  the  following  factors  : 

a.  Age.     The  incubation  is  shorter  in  children  than  in  adults. 

b.  The  part  infected.  The  rapidity  of  onset  of  the  symptoms 
is  greatly  determined  by  the  part  of  the  body  which  may  happen 
to  have  been  bitten.  Wounds  about  the  face  and  head  are  es- 
pecially dangerous  ;  next  in  order  in  degrees  of  mortality  come 
bites  on  the  hands,  then  injuries  on  the  other  parts  of  the  body. 
This  relative  order  is,  no  doubt,  greatly  dependent  upon  the  fact 
that  the  face,  head,  and  hands  are  usually  naked,  while  the  other 
parts  are  clothed. 

c.  The  extent  and  severity  of  the  wound.  Punctured  wounds 
are  the  most  dangerous  ;  the  lacerations  are  fatal  in  proportion 
to  the  extent  of  the  surface  afforded  for  absorption  of  the  virus. 

d.  The  animal  conveying  the  infection.  In  order  of  decreas- 
ing severity   come:  first,   the   wolf;  second,   the  cat;  third,  the 


FALSE   HYDROPHOBIA.  479 

dog  ;  and  fourth,  other  animals.     Only  about  fifteen  per  cent,  of 
those  bitten  by  rabid  dogs  become  affected  by  the  disease. 

Symptoms. — i.  The  premonitory  stage,  which  lasts  for  one  or 
two  .days.  The  patients  complain  of  headache,  irritability,  ap- 
prehension of  evil,  sleeplessness,  increased  sensibility  to  light 
and  noise,  loss  of  appetite,  huskiness  of  the  voice,  commencing 
difficulty  in  swallowing,  a  slight  rise  of  the  pulse  and  tempera- 
ture, and  pain  in  the  cicatrix  of  the  bite. 

2.  The  convulsive  stage.  First,  the  muscles  of  deglutition 
are  easily  excited  to  involuntary  and  painful  contractions.  Then 
the  muscles  of  respiration,  and  the  voluntary  muscles  throughout 
the  body  are  affected  in  the  same  way.  The  saliva  is  increased 
in  quantity,  and  the  patients  are  constantly  spitting  it  out.  They 
vomit  the  little  food  they  are  able  to  swallow.  There  is  venous 
congestion  of  the  skin.  There  is  violent  delirium  with  hallucina- 
tions. The  heart's  action  becomes  rapid  and  feeble.  The  pa- 
tients die  exhausted  in  from  one  to  ten  days.  The  incessant  con- 
vulsive movements  and  violent  delirium  give  a  terrible  clinical 
picture.     The  temperature  may  rise  from  ioo°  to  103°  F. 

3.  The  paralytic  stage.  In  rodents  the  preliminary  and  furi- 
ous stages  are  absent  as  a  rule,  and  the  paralytic  stage  may  be 
marked  from  the  outset — dumb  rabies.  During  this  stage  the 
patients  become  quiet,  the  spasms  no  longer  occur,  there  is  grad- 
ual unconsciousness,  and  the  heart's  action  becomes  more  and 
more  feeble. 

Treatment. — The  bite  of  a  rabid  animal  should  be  at  once  ex- 
cised or  freely  cauterized. 

During  the  period  of  incubation  inoculation  with  attenuated 
virus  from  the  spinal  cords  of  rabbits,  after  the  method  of  Pas- 
teur, has  given  good  results. 

During  the  convulsive  period  morphine  and  chloroform  may 
be  used  very  liberally. 

False   Hydrophobia. 

This  is  a  curious  affection,  which  closely  resembles  hydro- 
phobia, but  is  really  nothing  more  than  a  neurotic  or  hysterical 
manifestation.  A  nervous  person  bitten  by  a  dog,  whether  rabid 
or  not,  develops  after  several  months  symptoms  resembling  those 
of  rabies.  These  attacks  last  longer  than  those  of  true  rabies, 
and  are  amenable  to  treatment. 


TRICHINOSIS. 


This  is  an  infectious  disease  belonging  to  swine.  It  is  due  to 
the  introduction  into  the  body  of  a  species  of  worm — tiie  trichina. 

In  man  the  disease  is  acquired  by  eating  swine's  flesh  which 
contains  living  trichinae. 

When  flesh  containing  trichinae  is  taken  into  the  stomach,  the 
trichinae  are  set  free  and  pass  into  the  small  intestine.  There 
they  become  mature  within  two  or  three  days,  and  the  females 
bring  forth  living  young  five  days  later. 

The  trichinae  are  of  the  shape  of  thread-like  worms,  male  and 
female.  The  male  are  i^  mm.  long,  the  female  3  to  4  mm.  long. 
The  young  are  born  alive  on  the  seventh  day  after  the  ingestion 
of  the  flesh  containing  trichinae. 

The  young  trichinae  soon  leave  the  small  intestine  and  find  their 
way  into  the  voluntary  muscles.  Here  they  increase  somewhat 
in  size  and  become  enclosed  in  a  connective-tissue  capsule.  En- 
closed in  this  capsule  the  worm  remains  quiet  but  alive  for  years. 
Finally  it  dies,  and  the  capsule  becomes  thickened  and  infiltrated 
with  lime. 

The  syjnptoms  vary  with  the  number  of  trichinae  introduced 
into  the  stomach  and  born  in  the  small  intestine. 

A  small  number  of  trichinae  produce  very  slight  symptoms. 

A  large  number  of  trichinae  produce  severe  symptoms. 

From  a  few  hours  to  several  days  after  the  ingestion  of  the 
infected  meat  there  are  disturbances  of  the  stomach  and  bowels, 
pain,  vomiting,  and  diarrhoea,  with  prostration. 

About  the  tenth  day  begins  the  emigration  of  the  young 
worms  from  the  intestine  and  their  lodgement  in  the  muscles. 
While  this  is  going  on  the  muscles  are  swollen,  contracted,  ten- 
der, and  painful  ;  there  is  subcutaneous  oedema  in  different  parts 
of  the  body  ;  there  are  irregular  eruptions  of  herpetic,  petechial, 
or  pustular  form  ;  there  is  a  continued  fever  with  progressive 
emaciation  ;  the  patients  pass  into  the  typhoid  state  ;  there  may 
be  a  complicating  bronchitis  or  broncho-pneumonia. 

The   disease  lasts   from   eleven   to  one   hundred   and  twenty 


TRICHINOSIS.  481 

days.  It  is  often  fatal.  In  the  cases  which  recover  convales- 
cence is  protracted. 

Treatment. — The  preventive  treatment  consists  in  an  efficient 
inspection  of  the  muscles  of  all  swine  that  are  slaughtered  and 
in  the  thorough  cooking  of  all  swine  flesh  that  is  eaten. 

During  the  first  seven  days  after  the  ingestion  of  infected 
flesh  it  is  possible  to  get  rid  of  some  of  the  trichinae  by  vomiting 
and  purging  the  patients. 


ANTHRAX. 


(Malignant  Pustule.     Malignant  QEdema.      Milzbrand.) 

An  infectious  disease  belonging  to  cattle,  sheep,  and  horses,, 
and  which  is  communicated  from  these  animals  to  man. 

The  characteristic  micro-organism  is  a  bacillus  which  is  found 
in  great  numbers  in  the  blood,  and  which  can  be  cultivated  and 
inoculated. 

These  bacilli  may  live  for  a  long  time  in  the  grass  and  on  the 
surface  of  the  ground.  They  may  originate  on  marshy  soils,  or 
may  be  brought  there  by  diseased  cattle.  Cattle  acquire  the 
disease  from  food  and  air  contaminated  with  the  bacilli. 

In  man  the  disease  is  acquired  by  inoculation,  by  inhalation, 
or  by  the  alimentary  canal.  Inoculation  is  effected  by  handling 
infected  hides,  hair,  wool,  flesh,  or  instruments.  It  is  said  that 
it  can  also  be  done  by  flies  and  mosquitoes.  The  inhalation  is 
of  the. dust  from  infected  hides,  hair,  or  wool.  The  introduction 
into  the  stomach  of  infected  flesh  can  give  the  disease. 

Symptoms, — The  disease  in  man  regularly  follows  one  of  three 
forms: 

I.  Malignant  Pustule.  This  is  the  most  common  form.  It  is 
acquired  by  inoculation.  There  is  a  period  of  incubation  lasting 
from  a  few  hours  to  fourteen  days. 

At  the  point  of  inoculation  there  is  first  a  little  swelling  look- 
ing like  a  flea-bite,  with  a  central  black  point.  This  swelling 
becomes  larger,  a  vesicle  is  formed  on  it,  then  there  is  a  central 
dry  necrosis  surrounded  by  a  thick,  swollen,  red  zone  looking 
like  a  carbuncle,  and  around  this  the  skin  is  swollen  and  oedema- 
tous.  The  general  symptoms  are  developed  from  forty-eight  to 
sixty  hours  after  the  appearance  of  the  pustule.  There  are  fever, 
prostration,  and  the  rapid  development  of  the  typhoid  state. 

The  disease  lasts  from  two  to  thirty  days.  It  is  very  apt  to 
prove  fatal. 


GLANDERS — FARCY.  483 

2.  Malignant  (Edema.  This  is  acquired  by  eating  infected 
meat  or  breathing  infected  air. 

After  eating  infected  flesh  tlie  symptoms  begin  in  from  eight 
to  forty- eight  hours. 

The  patients  have  chills,  nausea,  vomiting,  pain  in  the  abdo- 
men, and  great  prostration.  After  hours  or  days  a  subcutaneous 
oedema  of  some  part  of  the  body  is  developed. 

This  form  of  anthrax  is  very  fatal. 

3.  Intestinal  Anthrax.  This  is  acquired  by  eating  infected 
meat. 

The  patients  suffer  from  prostration,  pains  in  the  head  and 
limbs,  pains  in  the  abdomen,  vomiting,  bloody  diarrhoea,  rapid 
breathing,  restlessness,  stupor,  convulsions,  high  or  low  tempera- 
ture, bleeding  from  the  mouth.  In  the  more  protracted  cases 
carbuncles  are  formed  on  the  arms  or  head.  This  form  of  the 
disease  is  very  fatal  ;  the  patients  die  in  from  one  to  seven  days. 

Treatment. — Preventive  treatment  is  directed  to  cattle  and 
sheep.  Diseased  animals  are  destroyed,  suspected  animals  are 
isolated,  and  inoculations  with  attenuated  virus  have  been  prac- 
tised with  success  on  a  large  scale. 

In  malignant  pustule  the  site  of  inoculation  should  be  de- 
stroyed by  caustics  or  the  actual  cautery,  and  the  bichloride  of 
mercury  may  be  sprinkled  over  the  exposed  surface.  The  sub- 
cutaneous connective  tissue  around  the  pustule  may  be  injected 
with  solutions  of  corrosive  sublimate  or  of  carbolic  acid.  The 
local  application  to  the  pustule  of  powdered  ipecac  mixed  with 
water,  and  at  the  same  time  the  internal  use  of  ipecac  in  five- 
grain  doses  every  three  hours,  is  highly  recommended. 

Glanders — Farcy. 

These  names  are  given  to  an  infectious  disease  of  the  horse 
which  is  sometimes  communicated  to  man.  The  disease  follows 
two  forms  as  to  the  locality  of  its  intlammatory  lesions.  There 
is  an  inflammation  of  the  mucous  membrane  of  the  nose,  with 
the  formation  of  nodules — glanders  ;  or  an  inflammation  of  the 
lymphatic  glands,  with  the  formation  of  nodules  in  the  skin — 
farcy. 

Causes. — The  micro-organism  of  the  disease  was  discovered  by 
Loffler  and  Schlitz.  It  is  a  short  bacillus  not  unlike  that  of 
tubercle.     Human  beings  become    affected  by  contact  with  dis- 


484  GLANDERS— FARCY. 

eased  animals,  usually  by  inoculation  on  an  abraded  surface  of 
the  skin.  The  contagion  may  also  be  received  on  one  of  the 
mucous  membranes. 

Lesions. — -The  essential  lesion  is  the  formation  of  the  tumors 
composed  of  round  cells  in  the  mucous  membranes  and  in  the 
skin,  sometimes  also  in  the  viscera.  These  nodules  have  a  dis- 
position to  become  necrotic  and  soften,  and  so  form  ulcers. 
Besides  the  formation  of  these  nodules,  there  is  inflammation 
of  the  mucous  membrane  of  the  nose  and  of  the  lymphatic 
glands. 

Acute  Gla7iders. — Symptoms.  The  period  of  incubation  is  rarely 
more  than  three  or  four  days.  At  the  point  of  infection  there 
are  redness,  swelling,  and  lymphangitis.  Within  a  few  days  the 
mucous  membrane  of  the  nose  becomes  inflamed  and  coated  with 
a  muco-purulent  discharge,  while  nodules  are  form.ed  in  its 
stroma.  The  nodules  soon  soften  and  form  ulcers.  An  erup- 
tion of  papulae,  which  rapidly  become  pustules,  breaks  out  over 
the  face  and  about  the  joints.  This  eruption  has  been  mistaken 
for  that  of  variola.  The  nose  becomes  much  swollen,  the  dis- 
charge from  it  is  abundant  and  offensive.  The  lymphatic 
glands  in  the  neck  are  swollen.  Inflammation  of  the  lungs 
is  often  developed.  There  is  a  febrile  movement  throughout. 
The  disease  runs  its  course  within  ten  days  and  is  invariably 
fatal. 

Chro7iic  Glanders  is  of  rare  occurrence,  and  may  be  mistaken 
for  a  chronic  catarrhal  inflammation  of  the  nose.  There  is  a  dis- 
charge of  mucus  from  the  nose  and  the  formation  of  chronic 
ulcers  in  its  mucous  membrane.  The  disease  lasts  for  a  number 
of  months,  and  recovery  is  possible. 

Acute  Farcy. — At  the  point  of  inoculation  a  little  tumor  is 
formed,  surrounded  by  inflamed  skin.  This  soon  degenerates  and 
forms  an  unhealthy  ulcer.  Then  the  adjacent  lymphatic  vessels 
and  glands  become  inflamed,  nodules  are  formed  in  the  skin,  the 
joints  become  inflamed,  and  abscesses  are  formed  in  different 
parts  of  the  body.  The  patients  give  the  symptoms  of  virulent 
poisoning,  they  have  headache,  delirium,  stupor,  a  febrile  move- 
ment, rapid  emaciation,  and  great  prostration.  The  disease  runs 
its  course  in  from  twelve  to  fifteen  days,  and  is  fatal  in  a  large 
proportion  of  the  cases. 

Chronic  Farcy  is  characterized  by  the  presence  of  localized 
tumors,  which  are    usually  situated  on  the  extremities.     These 


GLANDERS— FARCY.  485 

tumors  break  down  and  form  abscesses  and  ulcers,  but  without 
inflammation  of  the  lymphatics.  The  disease  may  last  for  months 
or  years.  Death  may  result  from  pyaemia  or  from  acute  glanders. 
Recovery  is  possible. 

Treatment. — The  original  wound  or   tumor  should  be  cut  out 
or  destroyed  by  caustics. 


ACTINOMYCOSIS.* 


The  disease  belongs  to  the  class  of  infective  granulomata.  It 
is  a  chronic  inflannmation  excited  by  the  presence  of  a  special 
microphyte,  with  the  production  of  new  tissue  composed  of 
a  stroma,  round  cells,  epithelioid  cells,  and  giant  cells,  which 
closely  resemble  tubercle  tissue.  The  new  tissue  forms  tumors 
of  varying  size,  which  often  degenerate  and  suppurate. 

The  disease  has  existed  for  a  long  time  in  cattle  under  a  va- 
riety of  names  ;  it  is  only  later  that  it  has  been  recognized  in  hu- 
man beings.     It  has  also  been  observed  in  pigs  and  horses. 

It  is  most  frequently  seen  in  young  cattle  between  the  ages 
of  one  and  three  years,  but  it  may  occur  at  any  age. 

It  is  probable  that  the  micro-organism  gains  access  to  the  sys- 
tem through  wounds  of  the  skin  and  mucous  membranes,  or 
through  carious  teeth.  The  cow-sheds,  pastures,  and  drinking- 
tanks  may  be  infected  by  the  discharges  from  diseased  animals. 

Actinomycosis  of  the  lips  occurs  in  the  form  of  rounded  nod- 
ules, or  flat,  wart-like  growths,  or  ulcers,  or  polypoid  growths  of 
considerable  size. 

In  the  upper  and  lower  jaws  the  disease  seems  to  originate  in 
carious  teeth  and  then  extends  to  the  bone,  which  becomes  the 
seat  of  chronic  inflammation  with  enlargement. 

The  tongue  is  enlarged,  is  the  seat  of  a  diffuse  inflammation, 
and  is  studded  with  nodules  which  may  suppurate  or  ulcerate. 

In  the  pharynx  the  growth  assumes  the  form  of  submucous, 
polypoid  tumors.  Similar  growths  are  found  in  the  larynx  and 
trachea. 

In  any  part  of  the  body  tumors  may  be  found  in  the  deeper 
layers  of  the  skin,  which  may  suppurate. 

In  the  lungs  are  found  nodules  which  look  like  miliary  tuber-, 
cles. 

The  actinomyces  may  be  seen  with  the  naked  eye  in  the  muco- 
purulent discharge  or  in  the  scrapings  from  a  growth.     The  tufts 

*  Report  of  the  Agricultural  Department.     London,  18S9.     Crookshank. 


ACTINOMYCOSIS.  487 

of  the  fungus  vary  in  size  from  that  of  a  grain  of  sand  to  that  of 
a  pin's  head.  They  are  made  up  of  aggregations  of  club-shaped 
rods  which  form  a  sort  of  rosette.     They  may  be  calcified. 

In  the  human  subject  actinomycosis  affects  the  tissues  of  the 
mouth  and  neck  and  the  jaws,  producing  lesions  which  come  un- 
der the  care  of  the  surgeon  ;  and  the  lungs  and  the  gastro-intes- 
tinal  tract,  which  come  under  the  care  of  the  physician. 

Thirty-three  cases  of  actinomycosis  of  the  lungs  have  been 
collected  by  Dr.  Hodenpyle,  from  which  the  following  account 
has  been  prepared  : 

The  ages  of  the  patients  varied  from  nine  to  sixty-three  years  ; 
the  majority  of  the  patients  were  young  adults. 

The  symptoms  were  those  of  a  subacute  broncho-pneumonia  : 
cough  and  muco-purulent  sputa,  sometimes  fetid,  sometimes  con- 
taining actinomyces  ;  the  physical  signs  of  bronchitis  and  of  con- 
solidation of  part  of  one  lung  ;  an  irregular  febrile  movement, 
and  progressive  loss  of  fliesh  and  strength.  In  some  of  the  pa- 
tients the  formation  of  abscesses  in  the  wall  of  the  chest,  so  that 
they  were  mistaken  for  cases  of  empyema. 

The  average  duration  of  the  disease  was  ten  months. 

Lesions. — Usually  only  one  lung  is  involved.  The  lesions  are 
those  of  a  broncho-pneumonia  of  peculiar  form.  The  bronchi  con- 
tain pus  and  actinomyces.  Their  walls  are  thickened  by  a  growth 
of  granulation-tissue  or  by  little  abscesses.  Polypoid  growths  of 
granulation-tissue  project  inward  from  the  walls  of  the  bronchi, 
and  irregular  masses  of  organized  connective  tissue  are  found 
in  their  cavities.  The  walls  of  the  air-spaces  are  thickened,  their 
cavities  are  filled  with  epithelium  or  organized  connective  tissue. 
In  some  places  are  masses  of  granulation  or  connective  tissue  ob- 
literating the  air-spaces. 

Diagnosis. — In  all  cases  of  broncho-pneumonia  of  irregular 
type  the  sputa  should  be  examined  for  actinomyces. 

Prognosis. — Nearly  all  the  cases  thus  far  reported  have  proved 
fatal. 

Treatment. — The  indications  seem  to  be  to  use  systematic  in- 
halations of  creosote,  and  to  open  and  scrape  out  the  abscesses  in 
the  wall  of  the  chest. 


-jOK.m^BIA  U^nVI'RSIT 


